Direct carotid puncture is an important option in endovascular surgery when a guiding catheter is not advanced into the common carotid artery because of arterial tortuosity. However, hemostasis after the procedure is not easy and hematoma formation from the puncture site sometimes causes serious complications. We present our carotid angioplasty and stenting (CAS) method with a direct carotid puncture and a small incision. An 85-year-old male with transient ischemic attack had severe left carotid artery stenosis. CAS was planned considering his age, but arterial tortuosity prevented a guiding catheter from being introduced into the left common carotid artery. Following this, the left common carotid artery was exposed with a small skin incision under local anesthesia, and a direct carotid puncture was made. A 7-French short sheath was carefully advanced and positioned into the left common carotid artery and a self-expandable stent was delivered through it. Upon completion of the procedure, the puncture point of the vascular wall was sutured with 6-0 proline immediately after withdrawing the sheath, and the skin was closed. A direct carotid puncture with a small incision can be performed safely. This method can reliably stop bleeding from the puncture site and also avoid the need for prolonged manual compression of the carotid artery under systemic anticoagulation and antiplatelet therapy. We think our method is useful for accessing corotid artery stenosis when the transfemoral approach is difficult.