OBJECTIVES: Carotid endarterectomy (CEA) has been recommended as the gold standard for the management of carotid disease in many clinical guidelines. But, in Korean clinical practice, carotid artery stening (CAS) was conducted more than CEA (21.6%) based on the national claims-data. The purpose of this study was to compare the effectiveness with CAS and CEA in 677 patients with symptomatic carotid artery stenosis in korean clinical practice. METHODS: From January 1 2008 to December 31 2011, retrospective cohort study was conducted in 677 symptomatic carotid stenosis patients with more than 50% stenosis) (CAS=346, CEA=331) in the Korean hospitals (Asan medical center, Samsung medical center, Severance hospital, Inha university hospital, Chonnam university hospital). The primary outcome was stroke, myocardial infarction, or death during periprocedural (30-day) and postprocedural period. RESULTS: For 677 patients over 2-year follow-up period, All death, major stroke, minor stroke were higher in CAS group than CEA (1.45% vs. 0.30%, 4.05% vs. 1.81%, 3.47% vs. 3.02%, 0.58% vs. 0%). All outcomes were higher in CAS than in CEA within 30-day after treatment and in subsequent years, except the incidence of 30 days-minor stroke. CONCLUSIONS: CEA was superior to CAS in symptomatic patients with carotid stenosis. This study suggests that CEA can be considered the first-line therapy for symptomatic carotid artery stenosis in South Korea.