Objective Carotid angioplasty and stenting (CAS) has been suggested to be the procedure of choice in patients with high risk cardiovascular profile. Unfortunately, such patients are often aged with several comorbidities, such as a high prevalence of coronary artery disease, peripheral artery disease and hostile anatomy that complicate the CAS performance. We sought to evaluate the results of CAS in elderly patients, outlining the encountered challenges and the eventual proposed global cardiovascular management. Methods We retrospectively searched the database for patients > 65-year-old who were referred to Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, over a 24-month period (December 2007-November 2009) for CAS. Coronary angiography and peripheral screening were performed in all patients. All eventual challenges and related solutions were analyzed. Results Totally, 160 patients were enrolled. Among which, 50 patients (31.2%, mean age 80 ±6.4 years) underwent CAS over a 24-month period: 24 patients (48%) had concurrent coronary artery disease (three-vessel in 7 patients, bivessel in 8 patients, single vessel in S patients and left main in 4 patients); 13 patients (26%) and peripheral artery disease at the site of arterial access; IS patients and type III aortic arch (30%), 7 patients severe tortuosity of the common carotid artery (14%), and 8 angulated takeoff of carotid or internal artery (16%). Concurrent percutaneous coronary intervention was performed in 14 patients, including 3 patients with left main disease. Concurrent peripheral intervention was performed in 7 patients ( all with bilateral common or external critical disease) due to the impossibility to gain another access. Successful carotid cannulation was achieved in all patients with hostile neck. Two-wire technique has been used in 17 patients, three-wire technique in 9 patients, and four-wire technique in 4 patients. Conclusion Elderly patients submitted to CAS represent a complex and challenging subgroup in which often cardiac and peripheral technical expertise is required to gain success of the procedure: interventional cardiologists are probably the preferred performers in such complex patients.