ATHENS — Many national/international guidelines provide recommendations on management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis. Several questions remain unanswered, however, according to a new report.
An international, multispecialty, expert-based Delphi Consensus document sought to address those issues to help clinicians make decisions when guidelines are unclear. Researchers from the Baltimore VAMC participated in the effort, which was led by Greek experts from the Central Clinic of Athens.
A 3-round Delphi Consensus process was performed, including 61 experts who considered 14 controversial topics. Results were published in the Journal of Vascular Surgery.1
Most experts agreed that:
- 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,
- 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,
- 80-99% AsxCS carries a higher risk of stroke, compared with 60-79% AsxCS,
- 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,
- 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.
“The present international, multispecialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues,” the authors wrote. “However, consensus could not be achieved on some topics, highlighting areas requiring future research.”
- Paraskevas KI, Mikhailidis DP, Ringleb PA, Brown MM, et. al. An International, Multispecialty, Expert-Based Delphi Consensus Document on Controversial Issues in the Management of Patients with Asymptomatic and Symptomatic Carotid Stenosis. J Vasc Surg. 2023 Nov 7:S0741-5214(23)02059-1. doi: 10.1016/j.jvs.2023.09.031. Epub ahead of print. PMID: 37944771.