An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis

Kosmas I. Paraskevas; Dimitri P. Mikhailidis; Peter Arthur Ringleb; Martin M. Brown; Alan Dardik; Pavel Poredos; William A. Gray; Andrew N. Nicolaides; Brajesh K. Lal; Armando Mansilha; Pier Luigi Antignani; Gert J. de Borst; Richard P. Cambria; Ian M. Loftus; Carl J. Lavie; Ales Blinc; Sean P. Lyden; Jon S. Matsumura; Mateja K. Jezovnik; J. Michael Bacharach; James F. Meschia; Daniel G. Clair; Clark J. Zeebregts; Gaetano Lanza; Laura Capoccia; Francesco Spinelli; Christos D. Liapis; Arkadiusz Jawien; Sahil A. Parikh; Alexei Svetlikov; Gabor Menyhei; Alun H. Davies; Piotr Musialek; Gary Roubin; Francesco Stilo; Sherif Sultan; Robert M. Proczka; Gianluca Faggioli; George Geroulakos; Jose Fernandes e Fernandes; Jean Baptiste Ricco; Luca Saba; Eric A. Secemsky; Rodolfo Pini; Piotr Myrcha; Tatjana Rundek; Ombretta Martinelli; Stavros K. Kakkos; Ravish Sachar; Guillaume Goudot; Felix Schlachetzki; George S. Lavenson; Stefano Ricci; Raffi Topakian; Antoine Millon; Vincenzo Di Lazzaro; Mauro Silvestrini; Seemant Chaturvedi; Hans Henning Eckstein; Peter Gloviczki; Christopher J. White

doi:10.1016/j.jvs.2023.09.031

An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis

Kosmas I. Paraskevas, Dimitri P. Mikhailidis, Peter Arthur Ringleb, Martin M. Brown, Alan Dardik, Pavel Poredos, William A. Gray, Andrew N. Nicolaides, Brajesh K. Lal, Armando Mansilha, Pier Luigi Antignani, Gert J. de Borst, Richard P. Cambria, Ian M. Loftus, Carl J. Lavie, Ales Blinc, Sean P. Lyden, Jon S. Matsumura, Mateja K. Jezovnik, J. Michael BacharachJames F. Meschia, Daniel G. Clair, Clark J. Zeebregts, Gaetano Lanza, Laura Capoccia, Francesco Spinelli, Christos D. Liapis, Arkadiusz Jawien, Sahil A. Parikh, Alexei Svetlikov, Gabor Menyhei, Alun H. Davies, Piotr Musialek, Gary Roubin, Francesco Stilo, Sherif Sultan, Robert M. Proczka, Gianluca Faggioli, George Geroulakos, Jose Fernandes e Fernandes, Jean Baptiste Ricco, Luca Saba, Eric A. Secemsky, Rodolfo Pini, Piotr Myrcha, Tatjana Rundek, Ombretta Martinelli, Stavros K. Kakkos, Ravish Sachar, Guillaume Goudot, Felix Schlachetzki, George S. Lavenson, Stefano Ricci, Raffi Topakian, Antoine Millon, Vincenzo Di Lazzaro, Mauro Silvestrini, Seemant Chaturvedi, Hans Henning Eckstein, Peter Gloviczki, Christopher J. White

Neurology

Research output: Contribution to journal › Review article › peer-review

Abstract

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 three-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 resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. Results: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) 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; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) 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.

Original language	English (US)
Pages (from-to)	420-435.e1
Journal	Journal of vascular surgery
Volume	79
Issue number	2
DOIs	https://doi.org/10.1016/j.jvs.2023.09.031
State	Published - Feb 2024

Keywords

Asymptomatic carotid stenosis
Delphi Consensus
Stroke
Symptomatic carotid stenosis
Transient ischemic attack

ASJC Scopus subject areas

Surgery
Cardiology and Cardiovascular Medicine

Access to Document

10.1016/j.jvs.2023.09.031

Cite this

Paraskevas, K. I., Mikhailidis, D. P., Ringleb, P. A., Brown, M. M., Dardik, A., Poredos, P., Gray, W. A., Nicolaides, A. N., Lal, B. K., Mansilha, A., Antignani, P. L., de Borst, G. J., Cambria, R. P., Loftus, I. M., Lavie, C. J., Blinc, A., Lyden, S. P., Matsumura, J. S., Jezovnik, M. K., ... White, C. J. (2024). An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis. Journal of vascular surgery, 79(2), 420-435.e1. https://doi.org/10.1016/j.jvs.2023.09.031

An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis. / Paraskevas, Kosmas I.; Mikhailidis, Dimitri P.; Ringleb, Peter Arthur et al.
In: Journal of vascular surgery, Vol. 79, No. 2, 02.2024, p. 420-435.e1.

Research output: Contribution to journal › Review article › peer-review

Paraskevas, KI, Mikhailidis, DP, Ringleb, PA, Brown, MM, Dardik, A, Poredos, P, Gray, WA, Nicolaides, AN, Lal, BK, Mansilha, A, Antignani, PL, de Borst, GJ, Cambria, RP, Loftus, IM, Lavie, CJ, Blinc, A, Lyden, SP, Matsumura, JS, Jezovnik, MK, Bacharach, JM, Meschia, JF, Clair, DG, Zeebregts, CJ, Lanza, G, Capoccia, L, Spinelli, F, Liapis, CD, Jawien, A, Parikh, SA, Svetlikov, A, Menyhei, G, Davies, AH, Musialek, P, Roubin, G, Stilo, F, Sultan, S, Proczka, RM, Faggioli, G, Geroulakos, G, Fernandes e Fernandes, J, Ricco, JB, Saba, L, Secemsky, EA, Pini, R, Myrcha, P, Rundek, T, Martinelli, O, Kakkos, SK, Sachar, R, Goudot, G, Schlachetzki, F, Lavenson, GS, Ricci, S, Topakian, R, Millon, A, Di Lazzaro, V, Silvestrini, M, Chaturvedi, S, Eckstein, HH, Gloviczki, P & White, CJ 2024, 'An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis', Journal of vascular surgery, vol. 79, no. 2, pp. 420-435.e1. https://doi.org/10.1016/j.jvs.2023.09.031

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title = "An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis",

abstract = "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 three-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 resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. Results: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) 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; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) 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.",

keywords = "Asymptomatic carotid stenosis, Delphi Consensus, Stroke, Symptomatic carotid stenosis, Transient ischemic attack",

author = "Paraskevas, {Kosmas I.} and Mikhailidis, {Dimitri P.} and Ringleb, {Peter Arthur} and Brown, {Martin M.} and Alan Dardik and Pavel Poredos and Gray, {William A.} and Nicolaides, {Andrew N.} and Lal, {Brajesh K.} and Armando Mansilha and Antignani, {Pier Luigi} and {de Borst}, {Gert J.} and Cambria, {Richard P.} and Loftus, {Ian M.} and Lavie, {Carl J.} and Ales Blinc and Lyden, {Sean P.} and Matsumura, {Jon S.} and Jezovnik, {Mateja K.} and Bacharach, {J. Michael} and Meschia, {James F.} and Clair, {Daniel G.} and Zeebregts, {Clark J.} and Gaetano Lanza and Laura Capoccia and Francesco Spinelli and Liapis, {Christos D.} and Arkadiusz Jawien and Parikh, {Sahil A.} and Alexei Svetlikov and Gabor Menyhei and Davies, {Alun H.} and Piotr Musialek and Gary Roubin and Francesco Stilo and Sherif Sultan and Proczka, {Robert M.} and Gianluca Faggioli and George Geroulakos and {Fernandes e Fernandes}, Jose and Ricco, {Jean Baptiste} and Luca Saba and Secemsky, {Eric A.} and Rodolfo Pini and Piotr Myrcha and Tatjana Rundek and Ombretta Martinelli and Kakkos, {Stavros K.} and Ravish Sachar and Guillaume Goudot and Felix Schlachetzki and Lavenson, {George S.} and Stefano Ricci and Raffi Topakian and Antoine Millon and {Di Lazzaro}, Vincenzo and Mauro Silvestrini and Seemant Chaturvedi and Eckstein, {Hans Henning} and Peter Gloviczki and White, {Christopher J.}",

note = "Publisher Copyright: {\textcopyright} 2023 Society for Vascular Surgery",

year = "2024",

month = feb,

doi = "10.1016/j.jvs.2023.09.031",

language = "English (US)",

volume = "79",

pages = "420--435.e1",

journal = "Journal of vascular surgery",

issn = "0741-5214",

publisher = "Mosby Inc.",

number = "2",

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TY - JOUR

T1 - An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis

AU - Paraskevas, Kosmas I.

AU - Mikhailidis, Dimitri P.

AU - Ringleb, Peter Arthur

AU - Brown, Martin M.

AU - Dardik, Alan

AU - Poredos, Pavel

AU - Gray, William A.

AU - Nicolaides, Andrew N.

AU - Lal, Brajesh K.

AU - Mansilha, Armando

AU - Antignani, Pier Luigi

AU - de Borst, Gert J.

AU - Cambria, Richard P.

AU - Loftus, Ian M.

AU - Lavie, Carl J.

AU - Blinc, Ales

AU - Lyden, Sean P.

AU - Matsumura, Jon S.

AU - Jezovnik, Mateja K.

AU - Bacharach, J. Michael

AU - Meschia, James F.

AU - Clair, Daniel G.

AU - Zeebregts, Clark J.

AU - Lanza, Gaetano

AU - Capoccia, Laura

AU - Spinelli, Francesco

AU - Liapis, Christos D.

AU - Jawien, Arkadiusz

AU - Parikh, Sahil A.

AU - Svetlikov, Alexei

AU - Menyhei, Gabor

AU - Davies, Alun H.

AU - Musialek, Piotr

AU - Roubin, Gary

AU - Stilo, Francesco

AU - Sultan, Sherif

AU - Proczka, Robert M.

AU - Faggioli, Gianluca

AU - Geroulakos, George

AU - Fernandes e Fernandes, Jose

AU - Ricco, Jean Baptiste

AU - Saba, Luca

AU - Secemsky, Eric A.

AU - Pini, Rodolfo

AU - Myrcha, Piotr

AU - Rundek, Tatjana

AU - Martinelli, Ombretta

AU - Kakkos, Stavros K.

AU - Sachar, Ravish

AU - Goudot, Guillaume

AU - Schlachetzki, Felix

AU - Lavenson, George S.

AU - Ricci, Stefano

AU - Topakian, Raffi

AU - Millon, Antoine

AU - Di Lazzaro, Vincenzo

AU - Silvestrini, Mauro

AU - Chaturvedi, Seemant

AU - Eckstein, Hans Henning

AU - Gloviczki, Peter

AU - White, Christopher J.

PY - 2024/2

Y1 - 2024/2

N2 - 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 three-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 resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. Results: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) 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; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) 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.

AB - 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 three-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 resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. Results: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) 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; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) 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.

KW - Asymptomatic carotid stenosis

KW - Delphi Consensus

KW - Stroke

KW - Symptomatic carotid stenosis

KW - Transient ischemic attack

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DO - 10.1016/j.jvs.2023.09.031

M3 - Review article

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VL - 79

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JO - Journal of vascular surgery

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An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis

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Keywords

ASJC Scopus subject areas

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