An International, Multispecialty, Expert-Based Delphi Consensus Document on Controversial Issues in the Management of Patients with Asymptomatic and Symptomatic Carotid Stenosis

Objective: Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. Methods: Fourteen controversial topics were identified. A 3-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was re-sent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. Results: Most experts agreed that: (i) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6 to 4% in SxCS and from 3 to 2% in AsxCS patients, (ii) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less, (iii) 80-99% AsxCS carries a higher risk of stroke compared with 60-79% AsxCS, (iv) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (e.g., plaque features of vulnerability and silent infarctions on brain CT scans), and, (v) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. Conclusions: The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.