An international, expert-based, multispecialty Delphi consensus document on stroke risk stratification and the optimal management of patients with asymptomatic and symptomatic carotid stenosis

OBJECTIVE: The optimal management of patients with asymptomatic carotid stenosis (AsxCS) and symptomatic carotid stenosis (SxCS) is controversial and includes intensive medical management (ie, best medical therapy [BMT]) with or without an additional carotid revascularization procedure (ie, carotid endarterectomy [CEA], transfemoral carotid artery stenting [TFCAS] or transcarotid artery revascularization [TCAR]). The aim of this international, expert-based, multispecialty Delphi consensus document was to reconcile the conflicting views regarding the optimal management of AsxCS and SxCS patients.

METHODS: A three-round Delphi consensus process was performed including 63 experts from Europe (n = 37) and the United States (n = 26). A total of six different clinical scenarios were identified involving patients with either AsxCS or SxCS. For each scenario, five treatment options were available: (i) BMT alone, (ii) BMT plus CEA, (iii) BMT plus TFCAS, (iv) BMT plus TCAR, and (v) BMT plus CEA/TFCAS/TCAR. Differences in treatment preferences between US and European participants were assessed using Fisher's exact test, and odds ratios were used to quantify the magnitude and direction of association. Consensus was achieved when >70% of the Delphi consensus participants agreed on a therapeutic approach.

RESULTS: Most participants concurred that BMT alone is not adequate for the management of a 70-year-old fit male or female patient with 80% to 99% AsxCS (52/63 [82.5%] and 45/63 [71.5%], respectively). In contrast, most panelists would opt for BMT alone for an 80-year-old male AsxCS patient with several comorbidities (48/63 [76.2%]). The majority of participants would opt for BMT plus a carotid revascularization procedure for an 80-year-old male SxCS patient with a recent ipsilateral cerebrovascular event, an ipsilateral 70% to 99% SxCS, and a 5-year predicted risk of ipsilateral ischemic event of 10% (54/63 [85.7%]), 15% (59/63 [93.6%]), or 20% (63/63 [100%]). The opinion of US-based participants varied from that of Europe-based respondents in some scenarios.

CONCLUSIONS: The panel agreed that BMT alone is insufficient for most patients with SxCS, and that select subgroups of AsxCS patients may also benefit from revascularization, especially when high-risk features are present. Patients should be stratified according to their predicted stroke risk, as well as their individual clinical, anatomical, and imaging features and should be treated accordingly.