This study supports the option of CAS in patients at elevated surgical risk. 9. In the CREST multicenter randomized clinical trial, CEA and CAS were directly compared in both symp- tomatic and asymptomatic patients. Among the 1321 symptomatic patients, over the 4-year study period, the primary end point (periprocedural stroke, death, or MI, plus later ipsilateral stroke) occurred in 8.6% of patients undergoing CAS and 8.4% of patients Both surgeons and intervention- alists were required to be credentialed for the study, and a periprocedural stroke/death rate of <6% (or lower) has been suggested in earlier statements. 10. TCAR is a relatively new endovascular technique that has several unique features. The interventional specialist directly accesses the common carotid artery, and flow reversal is provided to have blood drain to the femoral vein. A stent is placed at the site of ICA stenosis with no need to traverse the aortic arch. TCAR results have been analyzed in registries only thus far. A propensity score matched analysis compared TCAR with transfemoral CAS. Among 3286 patient pairs, approximately half of the patients were symptomatic. In symptomatic patients, TCAR, relative to transfemoral CAS, was associated with a lower rate of in-hospital stroke/death (2.1% versus 4.2%), stroke (2.0% versus 3.1%), and death TCAR has not been evalu- ated in randomized trials thus far and has not been compared with CEA or intensive medical therapy. 11. The combined analysis by Rothwell et al369 of CEA in patients with recent stroke or TIA found no ben- efit in patients with <50% ICA stenosis. 12. 