Introduction: Ischemic stroke constitutes a significant burden on global health. Carotid artery atherosclerosis is a significant contributor to the occurrence of ischemic strokes. Both carotid endarterectomy and stenting are viable treatment options for symptomatic carotid artery disease, yet the optimal choice between them remains debated, particularly in elderly patients with multiple comorbidities. This study aims to compare decision-making processes and early to mid-term outcomes between carotid endarterectomy and carotid artery stenting in elderly symptomatic carotid artery disease patients. Materials and Method: A total of 88 symptomatic carotid artery disease patients (carotid endarterectomy: n=35, mean age: 71.72±7.87 years; carotid artery stenting: n=53, mean age: 70.64±7.46 years) were retrospectively analyzed. Results: No significant differences were observed in demographic characteristics between carotid endarterectomy and stenting groups. Chronic renal disease was more prevalent in the carotid endarterectomy group. Carotid artery stenting patients had a higher prevalence of 50–69% stenosis and less plaque ulceration. Complication rates were comparable between groups, with longer intensive care and hospitalization durations in the carotid endarterectomy group. Mid-term mortality rates and major complications did not significantly differ between groups. Conclusion: Both carotid endarterectomy and carotid artery stenting are effective treatments for symptomatic carotid artery disease. Despite differences in lesion characteristics, complication rates were similar between carotid endarterectomy and carotid artery stenting. This study emphasized the efficacy of a full cooperation between the cardiovascular surgery and neurology teams through an in-depth evaluation of each of the patients and the creation of individualized treatment strategies that optimized overall outcomes.