Introduction While, long term and the efficacy of carotid intervention has been clearly documented, the natural history on symptomatic patients with ipsilateral carotid stenosis have not been well described in the contemporary era when best medical therapy has evolved. With an aging population and increase in frailty, information on medical management alone should be discussed with patients to assist in clinical decision-making. Therefore, the aim of our study is to assess the outcomes of symptomatic carotid artery stenosis that were managed non-operatively. Methods A prospective observational study was performed in a single Vascular tertiary referral centre in New Zealand. The study was carried out from 1 June 2019 to 1 January 2024. All symptomatic carotid artery disease referrals were included in the study. Kaplan Meier analysis was performed to assess stroke-free and age adjusted Cox proportional hazard models were used to determine all-cause survival. Results During the study period, a total of 280 patients were referred with symptomatic carotid disease. 84 (30.0%) patients were managed medically. The median (range) age was 76.5 years old (48-93). The three common reasons for patient being managed conservatively were below threshold for consideration of surgery (38, 43.2%), internal carotid artery (ICA) occlusion/near occlusion (22, 25.0%) and poor neurological recovery post stroke (10, 11.4%). There were six patients (7.1%) that developed a further stroke/transient ischaemic attack (TIA) following conservative management during the follow up period. The overall survival rate at 1 and 5 years were 86% and 57% respectively. The corresponding stroke free survival at 1 and 5 years were 94% and 92% respectively. Conclusion This data supports that patients who were not offered intervention for symptomatic carotid artery disease and were managed medically had a lower age adjusted overall survival compared to patients undergoing carotid intervention as well as a lower risk of future stroke.