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

Kosmas I Paraskevas¹, Ali F AbuRahma², Wesley S Moore³, Peter Gloviczki⁴, Bruce A Perler⁵, Daniel G Clair⁶, Christopher J White⁷, Carlo Setacci⁸, Eric A Secemsky⁹, Peter A Schneider¹⁰, Clark J Zeebregts¹¹, Armando Mansilha¹², Luca Saba¹³, Ian M Loftus¹⁴, Jeffrey Jim¹⁵, Christos D Liapis¹⁶, Vincenzo Di Lazzaro¹⁷, Alan Dardik¹⁸, Pavel Poredos¹⁹, Ankur Thapar²⁰, Salvatore T Scali²¹, Mario D'Oria²², Ales Blinc²³, Alexei Svetlikov²⁴, David H Stone²⁵, Sherif A H Sultan²⁶, Deniz Bulja²⁷, Michael C Stoner²⁸, Piotr Myrcha²⁹, Maarten Uyttenboogaart³⁰, Mark A Farber³¹, Gianluca Faggioli³², Domenica Crupi³³, Csaba Csobay-Novak³⁴, Jens Eldrup-Jorgensen³⁵, Gaetano Lanza³⁶, Gert J de Borst³⁷, Francesco Stilo³⁸, Meghan Dermody³⁹, Mauro Silvestrini⁴⁰, Christopher J Abularrage⁵, Guillaume Goudot⁴¹, Robert M Proczka⁴², Gary S Roubin⁴³, Francesco Spinelli³⁸, Gabor Menyhei⁴⁴, Saeid H Shahidi⁴⁵, Jose Ignacio Leal Lorenzo⁴⁶, Arkadiusz Jawien⁴⁷, Tilman Reiff⁴⁸, Laura Capoccia⁴⁹, José Fernandes E Fernandes⁵⁰, Piotr Musiałek⁵¹, Victor S Gurevich⁵², Matthew Blecha⁵³, Caitlin W Hicks⁵, Young M Erben⁵⁴, Mark F Conrad⁵⁵, Mahmoud B Malas⁵⁶, Sean P Lyden⁵⁷, Seemant Chaturvedi⁵⁸, Marc L Schermerhorn⁵⁹, Andrew N Nicolaides⁶⁰

Affiliations

¹ Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland. Electronic address: paraskevask@hotmail.com.
² Department of Surgery, Charleston Area Medical Center, West Virginia University, Charleston, WV.
³ Division of Vascular Surgery, University of California Los Angeles (UCLA) Medical Center, Los Angeles, CA.
⁴ Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
⁵ Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, The John Hopkins University School of Medicine, Baltimore, MD.
⁶ Department of Vascular Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN.
⁷ Department of Medicine and Cardiology, The John Ochsner Heart and Vascular Institute, New Orleans, LA; Department of Cardiology, University of Queensland School of Medicine, Brisbane, Australia.
⁸ Department of Vascular and Endovascular Surgery, Universita degli Studi di Siena, Siena, Italy.
⁹ Smith Center for Outcomes Research, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
¹⁰ Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA.
¹¹ Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands.
¹² Faculty of Medicine, University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. João, Porto, Portugal.
¹³ Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari, Cagliari, Italy.
¹⁴ St George's Vascular Institute, St George's University London, London, UK.
¹⁵ Department of Vascular & Endovascular Surgery, Allina Health Minneapolis Heart Institute, Minneapolis, MN.
¹⁶ Department of Vascular Surgery, Athens Medical Center, Athens, Greece.
¹⁷ Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Department of Medicine and Surgery, Campus Bio-Medico University, Rome, Italy; Department of Medicine, Fondazione Policlinico Campus Bio-Medico, Rome, Italy.
¹⁸ Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
¹⁹ Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.
²⁰ Mid and South Essex Vascular Unit, Mid and South Essex NHS Foundation Trust, Basildon, UK; Medical Technology Research Centre and School of Medicine, Anglia Ruskin University London, Chelmsford, UK.
²¹ Division of Vascular and Endovascular Therapy, University of Florida, Gainesville, FL.
²² Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Trieste, Italy.
²³ Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
²⁴ Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg State University, St. Petersburg, Russia.
²⁵ Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
²⁶ Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland.
²⁷ Neuroradiology Department, Radiology Clinic, Clinical center of Sarajevo University, Sarajevo, Bosnia and Herzegovina.
²⁸ Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
²⁹ Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland; Department of General, Vascular and Oncological Surgery, Hospital Bródnowski, Warsaw, Poland.
³⁰ Department of Neurology and Interventional Radiology, University Medical Center Groningen, Groningen, the Netherlands.
³¹ Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC.
³² Vascular Surgery Unit, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
³³ Head, Neck and Neuroscience Department, UOSD Stroke Unit, San Camillo Forlanin Hospital, Rome, Italy.
³⁴ Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
³⁵ Department of Surgery, Tufts University School of Medicine, Boston, MA.
³⁶ Department of Vascular Surgery, IRCCS Policlinico Multimedica, Sesto San Giovanni, Milan, Italy.
³⁷ Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
³⁸ Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University, Rome, Italy.
³⁹ Division of Vascular Surgery, Penn Medicine Lancaster General Hospital, Lancaster, PA.
⁴⁰ Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
⁴¹ Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France.
⁴² Faculty of Medicine, Lazarski University of Warsaw, Artevena Clinic Jozefow, Warsaw, Poland.
⁴³ CREST-2 Interventional Management Committee, Jackson, WY.
⁴⁴ Department of Vascular Surgery, University of Pécs, Pécs, Hungary.
⁴⁵ Department of Vascular and Endovascular Surgery, University Hospital Roskilde/Zealand University Hospital, Roskilde, Denmark.
⁴⁶ Vascular Surgery and Interventional Radiology Unit, Clinica Universidad de Navarra, Madrid, Spain.
⁴⁷ Department of Vascular Surgery and Angiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland.
⁴⁸ Department of Neurology, Neurovascular Study Center, University of Heidelberg, Heidelberg, Germany.
⁴⁹ Vascular and Endovascular Surgery Division, Department of Surgery, 'F. Spaziani' Hospital, Frosinone, Italy.
⁵⁰ Cardiovascular Center (CCUL), Faculty of Medicine University of Lisbon, Lisbon, Portugal; Department of Vascular Surgery, Hospital da Luz Torres de Lisboa, Lisbon, Portugal.
⁵¹ Department of Cardiac & Vascular Diseases, Jagiellonian University of Krakow, John Paul II Hospital, Krakow, Poland.
⁵² Center of Atherosclerosis and Lipid Disorders, North-Western State University n.a. I.I. Mechnikov, St. Petersburg State University, St. Petersburg, Russia.
⁵³ Division of Vascular Surgery, Stritch School of Medicine, Loyola University Chicago, Chicago, IL.
⁵⁴ Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
⁵⁵ Department of Surgery, Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston Medical Center Health System, Brighton, MA.
⁵⁶ Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA; Center for Learning & Excellent in Vascular & Endovascular Research (CLEVER), University of California San Diego, La Jolla, CA.
⁵⁷ Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH.
⁵⁸ Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD.
⁵⁹ Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
⁶⁰ Vascular Screening and Diagnostic Center, Nicosia, Cyprus; Department of Basic and Clinical Science, University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, UK.

PMID: 41005511
DOI: 10.1016/j.jvs.2025.09.039

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

Kosmas I Paraskevas et al. J Vasc Surg. 2025.

. 2025 Sep 24:S0741-5214(25)01773-2.

doi: 10.1016/j.jvs.2025.09.039. Online ahead of print.

Authors

Affiliations

¹ Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland. Electronic address: paraskevask@hotmail.com.
² Department of Surgery, Charleston Area Medical Center, West Virginia University, Charleston, WV.
³ Division of Vascular Surgery, University of California Los Angeles (UCLA) Medical Center, Los Angeles, CA.
⁴ Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
⁵ Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, The John Hopkins University School of Medicine, Baltimore, MD.
⁶ Department of Vascular Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN.
⁷ Department of Medicine and Cardiology, The John Ochsner Heart and Vascular Institute, New Orleans, LA; Department of Cardiology, University of Queensland School of Medicine, Brisbane, Australia.
⁸ Department of Vascular and Endovascular Surgery, Universita degli Studi di Siena, Siena, Italy.
⁹ Smith Center for Outcomes Research, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
¹⁰ Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA.
¹¹ Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands.
¹² Faculty of Medicine, University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. João, Porto, Portugal.
¹³ Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari, Cagliari, Italy.
¹⁴ St George's Vascular Institute, St George's University London, London, UK.
¹⁵ Department of Vascular & Endovascular Surgery, Allina Health Minneapolis Heart Institute, Minneapolis, MN.
¹⁶ Department of Vascular Surgery, Athens Medical Center, Athens, Greece.
¹⁷ Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Department of Medicine and Surgery, Campus Bio-Medico University, Rome, Italy; Department of Medicine, Fondazione Policlinico Campus Bio-Medico, Rome, Italy.
¹⁸ Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
¹⁹ Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.
²⁰ Mid and South Essex Vascular Unit, Mid and South Essex NHS Foundation Trust, Basildon, UK; Medical Technology Research Centre and School of Medicine, Anglia Ruskin University London, Chelmsford, UK.
²¹ Division of Vascular and Endovascular Therapy, University of Florida, Gainesville, FL.
²² Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Trieste, Italy.
²³ Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
²⁴ Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg State University, St. Petersburg, Russia.
²⁵ Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
²⁶ Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland.
²⁷ Neuroradiology Department, Radiology Clinic, Clinical center of Sarajevo University, Sarajevo, Bosnia and Herzegovina.
²⁸ Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
²⁹ Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland; Department of General, Vascular and Oncological Surgery, Hospital Bródnowski, Warsaw, Poland.
³⁰ Department of Neurology and Interventional Radiology, University Medical Center Groningen, Groningen, the Netherlands.
³¹ Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC.
³² Vascular Surgery Unit, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
³³ Head, Neck and Neuroscience Department, UOSD Stroke Unit, San Camillo Forlanin Hospital, Rome, Italy.
³⁴ Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
³⁵ Department of Surgery, Tufts University School of Medicine, Boston, MA.
³⁶ Department of Vascular Surgery, IRCCS Policlinico Multimedica, Sesto San Giovanni, Milan, Italy.
³⁷ Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
³⁸ Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University, Rome, Italy.
³⁹ Division of Vascular Surgery, Penn Medicine Lancaster General Hospital, Lancaster, PA.
⁴⁰ Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
⁴¹ Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France.
⁴² Faculty of Medicine, Lazarski University of Warsaw, Artevena Clinic Jozefow, Warsaw, Poland.
⁴³ CREST-2 Interventional Management Committee, Jackson, WY.
⁴⁴ Department of Vascular Surgery, University of Pécs, Pécs, Hungary.
⁴⁵ Department of Vascular and Endovascular Surgery, University Hospital Roskilde/Zealand University Hospital, Roskilde, Denmark.
⁴⁶ Vascular Surgery and Interventional Radiology Unit, Clinica Universidad de Navarra, Madrid, Spain.
⁴⁷ Department of Vascular Surgery and Angiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland.
⁴⁸ Department of Neurology, Neurovascular Study Center, University of Heidelberg, Heidelberg, Germany.
⁴⁹ Vascular and Endovascular Surgery Division, Department of Surgery, 'F. Spaziani' Hospital, Frosinone, Italy.
⁵⁰ Cardiovascular Center (CCUL), Faculty of Medicine University of Lisbon, Lisbon, Portugal; Department of Vascular Surgery, Hospital da Luz Torres de Lisboa, Lisbon, Portugal.
⁵¹ Department of Cardiac & Vascular Diseases, Jagiellonian University of Krakow, John Paul II Hospital, Krakow, Poland.
⁵² Center of Atherosclerosis and Lipid Disorders, North-Western State University n.a. I.I. Mechnikov, St. Petersburg State University, St. Petersburg, Russia.
⁵³ Division of Vascular Surgery, Stritch School of Medicine, Loyola University Chicago, Chicago, IL.
⁵⁴ Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
⁵⁵ Department of Surgery, Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston Medical Center Health System, Brighton, MA.
⁵⁶ Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, CA; Center for Learning & Excellent in Vascular & Endovascular Research (CLEVER), University of California San Diego, La Jolla, CA.
⁵⁷ Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH.
⁵⁸ Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD.
⁵⁹ Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
⁶⁰ Vascular Screening and Diagnostic Center, Nicosia, Cyprus; Department of Basic and Clinical Science, University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, UK.

PMID: 41005511
DOI: 10.1016/j.jvs.2025.09.039

Abstract

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.

Keywords: Asymptomatic carotid stenosis; Best medical therapy; Carotid artery stenting; Carotid endarterectomy; Stroke risk; Symptomatic carotid stenosis; Transcarotid artery revascularization.

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Conflict of interest statement

Disclosures M.C.S. has a consultant agreement with Boston Scientific. M.B.M. is a consultant to Cordis and Bard. P.A.S. is a consultant to Surmodics, Medtronic, Boston Scientific, Cagent, Acotec, Abbott, Endologix, Shockwave, Healthcare Inroads, Inari, and BD. M.K.E. is a paid consultant for W. L. Gore & Associates and Silkroad Medical (Boston Scientific). M.D. is a consultant/speaker for Boston Scientific Vascular and Medtronic Aortic. M.L.S. is PI for Medtronic, Boston Scientific and Shape clinical trials. He also does research with Cook, Terumo, and W. L. Gore & Associates. G.R. is the chair of the Interventional Management Committee of CREST-2. He is also InspireMD Inc. Director and stock holder. P.M. is co-principal investigator in the CGUARDIANS FDA-IDE and in the CARENET Trial and is principal investigator in the PARADIGM/PARADIGM-Extend, FLOWGUARD, OPTIMA, TOPGUARD, and SAFEGUARD-STROKE Carotid trials. He is a voting member of the ESC WG CARE, a member of the EuroPCR VITAL and EuroPCR Programme Producer and Session Quality Evaluator, and is a co-director of the ICCA/Stroke and Polish Cardiac Society Board Representative for Stroke and Vascular Interventions. He has proctored and/or consulted for Abbott Vascular, Balton, Gore, InspireMD, Medtronic, and Penumbra, and serves on the steering committee of the Medtronic SHIELD Study. S.P.L. is a consultant for BD, Boston Scientific, Contego Medical, Cordis, Endologix, Inspire MD, Medtronic, Rapid Medical, Shockwave, Penumbra, Vivasure, and Nectero. He has stock options in Inspire MD, Reva Medical, and Centerline Biomedical. He is a board member for VIVA Physicians. He has performed Research Studies for Abbott, Endologix, Surmodics, W. L. Gore & Associates, Terumo Aortic, NIH, Boston Scientific, Merit, Contego Medical, Inspire MD, Reva Medical, Penumbra, Medalliance, and Nectero.

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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

LinkOut - more resources

Full Text Sources

Medical