Although early on vascular surgeons rebuked the concept that carotid stenting could stand up against the gold standard of carotid endarterectomy, this minimally invasive treatment for carotid bifurcation disease has been shown to have surprisingly low rates of periprocedural complications and is clearly favored by patients, for whom avoidance of surgery reigns paramount. Unfortunately, reluctance to embrace this and other emerging endovascular technologies, as well as a variety of other factors to be discussed, has left vascular surgeons poorly positioned to participate in the delivery of these therapies to their patients. With estimates of up to 75% of carotid stenoses being suitable for treatment by this new modality, and with carotid endarterectomy being the most commonly performed vascular operation in the United States today, this is a significant problem for our specialty and one badly in need of a solution. An understanding of the myriad of underlying interrelated problems helps to provide insight into possible solutions.