An International, Expert-based, Multispecialty Delphi Consensus Document on Stroke Risk Stratification and the Optimal Management of Patients with Asymptomatic and Symptomatic Carotid Stenosis

An International, Expert-based, Multispecialty Delphi Consensus Document on Stroke Risk Stratification and the Optimal Management of Patients with Asymptomatic and Symptomatic Carotid Stenosis | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search An International, Expert-based, Multispecialty Delphi Consensus Document on Stroke Risk Stratification and the Optimal Management of Patients with Asymptomatic and Symptomatic Carotid Stenosis View ORCID Profile Kosmas I. Paraskevas , Ali F. AbuRahma , Wesley S. Moore , Peter Gloviczki , View ORCID Profile Bruce A. Perler , Daniel G. Clair , View ORCID Profile Christopher J. White , Carlo Setacci , View ORCID Profile Eric A. Secemsky , Peter A. Schneider , Clark J.A.M. Zeebregts , View ORCID Profile Armando Mansilha , View ORCID Profile Luca Saba , Ian M. Loftus , Jeffrey Jim , Christos D. Liapis , View ORCID Profile Vincenzo Di Lazzaro , View ORCID Profile Alan Dardik , Pavel Poredos , Ankur Thapar , View ORCID Profile Salvatore T. Scali , View ORCID Profile Mario D’Oria , Ales Blinc , View ORCID Profile Alexei Svetlikov , David H. Stone , Sherif A.H. Sultan , Deniz Bulja , Michael C. Stoner , View ORCID Profile Piotr Myrcha , View ORCID Profile Maarten Uyttenboogaart , View ORCID Profile Mark A. Farber , Gianluca Faggioli , Domenica Crupi , Csaba Csobay-Novak , Jens Eldrup-Jorgensen , Gaetano Lanza , View ORCID Profile Gert J. de Borst , Francesco Stilo , Meghan Dermody , View ORCID Profile Mauro Silvestrini , Christopher J. Abularrage , View ORCID Profile Guillaume Goudot , Robert M. Proczka , Gary S. Roubin , Francesco Spinelli , Gabor Menyhei , View ORCID Profile Saeid H. Shahidi , Jose Ignacio Leal Lorenzo , Arkadiusz Jawien , Tilman Reiff , Laura Capoccia , José Fernandes e Fernandes , Piotr Musiałek , Victor S. Gurevich , Matthew Blecha , View ORCID Profile Caitlin W. Hicks , Young M. Erben , View ORCID Profile Mark F. Conrad , Mahmoud B. Malas , View ORCID Profile Sean P. Lyden , View ORCID Profile Seemant Chaturvedi , Marc L. Schermerhorn , View ORCID Profile Andrew N. Nicolaides doi: https://doi.org/10.1101/2025.08.01.25332713 Kosmas I. Paraskevas 1 Department of Vascular Surgery, Red Cross Hospital , Athens, Greece 2 1st Chair and Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw , Warsaw, Poland MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Kosmas I. Paraskevas For correspondence: paraskevask{at}hotmail.com Ali F. AbuRahma 3 Department of Surgery, Charleston Area Medical Center, West Virginia University , Charleston, WV, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Wesley S. Moore 4 Division of Vascular Surgery, University of California Los Angeles (UCLA) Medical Center , Los Angeles, CA, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Peter Gloviczki 5 Division of Vascular and Endovascular Surgery, Mayo Clinic , Rochester, MN, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Bruce A. Perler 6 Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, The John Hopkins University School of Medicine , Baltimore, MD, U.S.A. MD, MBA Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Bruce A. Perler Daniel G. Clair 7 Department of Vascular Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences , Nashville, TN, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Christopher J. White 8 Department of Medicine and Cardiology, The John Ochsner Heart and Vascular Institute , New Orleans, LA, U.S.A. 9 Department of Cardiology, University of Queensland School of Medicine , Brisbane, Australia MD, MACC, MSCAI, FAHA, FESC, FACP Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Christopher J. White Carlo Setacci 10 Department of Vascular and Endovascular Surgery, Universita degli Studi di Siena , Siena, Italy MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Eric A. Secemsky 11 Smith Center for Outcomes Research, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center , Boston, MA, U.S.A. 12 Harvard Medical School , Boston, MA, U.S.A. MD, MSc, RPVI, FACC, FAHA, FSCAI, FSVM Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Eric A. Secemsky Peter A. Schneider 13 Division of Vascular and Endovascular Surgery, University of California San Francisco , San Francisco. CA, U.S.A. MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Clark J.A.M. Zeebregts 14 Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen , Groningen, The Netherlands MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Armando Mansilha 15 Faculty of Medicine, University of Porto , Porto, Portugal 16 Department of Angiology and Vascular Surgery, Hospital de S. João , Porto, Portugal MD, PhD, FIUA, FEBVS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Armando Mansilha Luca Saba 17 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) of Cagliari , Cagliari, Italy MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Luca Saba Ian M. Loftus 18 St George’s Vascular Institute, St George’s University London , London, United Kingdom MD, FRCS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Jeffrey Jim 19 Department of Vascular & Endovascular Surgery, Allina Health Minneapolis Heart Institute , Minneapolis, MN, U.S.A. MD, MPHS, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Christos D. Liapis 20 Department of Vascular Surgery, Athens Medical Center , Athens, Greece MD, FACS, FRCS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Vincenzo Di Lazzaro 21 Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Department of Medicine and Surgery, Campus Bio-Medico University , Rome, Italy 22 Fondazione Policlinico Universitario Campus Bio-Medico , Rome, Italy MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Vincenzo Di Lazzaro Alan Dardik 23 Department of Surgery, Yale School of Medicine , New Haven, Connecticut, U.S.A. 24 Department of Surgery, Icahn School of Medicine at Mount Sinai , New York, NY, U.S.A. MD, FACS, DFSVS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Alan Dardik Pavel Poredos 25 Department of Vascular Diseases, University Medical Centre Ljubljana , Ljubljana, Slovenia MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ankur Thapar 26 Mid and South Essex Vascular Unit, Mid and South Essex NHS Foundation Trust , Basildon, United Kingdom 27 Medical Technology Research Centre and School of Medicine, Anglia Ruskin University London , Chelmsford, United Kingdom PhD, FRCS, FEBVS, FHEA, PGCE Find this author on Google Scholar Find this author on PubMed Search for this author on this site Salvatore T. Scali 28 Division of Vascular and Endovascular Therapy, University of Florida , Florida, Gainesville, U.S.A. MD, FACS, DFSVS, RPVI Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Salvatore T. Scali Mario D’Oria 29 Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste , Trieste, Italy MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mario D’Oria Ales Blinc 25 Department of Vascular Diseases, University Medical Centre Ljubljana , Ljubljana, Slovenia 30 Department of Internal Medicine, Faculty of Medicine, University of Ljubljana , Ljubljana, Slovenia MD, DSc, FESC, EFE VAS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Alexei Svetlikov 31 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 MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Alexei Svetlikov David H. Stone 32 Section of Vascular Surgery, Dartmouth Hitchcock Medical Center , Lebanon, NH, U.S.A. MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sherif A.H. Sultan 33 Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway , Galway, Ireland MD, PhD, FRCS, FACS, FEBVS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Deniz Bulja 34 Neuroradiology department, Radiology Clinic, Clinical center of Sarajevo University , Sarajevo, Bosnia and Herzegovina MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Michael C. Stoner 35 Division of Vascular Surgery, University of Rochester Medical Center , Rochester, NY, U.S.A. MD, FACS, DFSVS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Piotr Myrcha 2 1st Chair and Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw , Warsaw, Poland 36 Department of General, Vascular and Oncological Surgery, Hospital Bródnowski , Warsaw, Poland MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Piotr Myrcha Maarten Uyttenboogaart 37 Department of Neurology and Interventional Radiology, University Medical Center Groningen , Groningen, The Netherlands MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Maarten Uyttenboogaart Mark A. Farber 38 Division of Vascular Surgery, University of North Carolina , Chapel Hill, NC, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mark A. Farber Gianluca Faggioli 39 Vascular Surgery Unit, Department of Medical and Surgical Sciences (DIMEC), University of Bologna , Bologna, Italy MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Domenica Crupi 40 Head, Neck and Neuroscience Department, UOSD Stroke Unit, San Camillo Forlanin Hospital , Rome, Italy MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Csaba Csobay-Novak 41 Department of Interventional Radiology, Heart and Vascular Center, Semmelweis University , Budapest, Hungary MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Jens Eldrup-Jorgensen 42 Department of Surgery, Tufts University School of Medicine , Boston, MA, U.S.A. MD, FACS, DFSVS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Gaetano Lanza 43 Department of Vascular Surgery, IRCCS Policlinico Multimedica , Sesto San Giovanni, Milan, Italy MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Gert J. de Borst 44 Department of Vascular Surgery, University Medical Center Utrecht , Utrecht, The Netherlands MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Gert J. de Borst Francesco Stilo 45 Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University , Rome, Italy MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Meghan Dermody 46 Division of Vascular Surgery, Penn Medicine Lancaster General Hospital , Lancaster, Pennsylvania, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Mauro Silvestrini 47 Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University , Ancona, Italy MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mauro Silvestrini Christopher J. Abularrage 6 Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, The John Hopkins University School of Medicine , Baltimore, MD, U.S.A. MD, DFSVS, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Guillaume Goudot 48 Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Université Paris Cité , Paris, France MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Guillaume Goudot Robert M. Proczka 49 Faculty of Medicine, Lazarski University of Warsaw; Artevena Clinic Jozefow , Warsaw, Poland MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Gary S. Roubin 50 CREST-2 Interventional Management Committee , Jackson, WY, U.S.A. MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Francesco Spinelli 45 Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University , Rome, Italy MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Gabor Menyhei 51 Department of Vascular Surgery, University of Pécs , Pécs, Hungary MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Saeid H. Shahidi 52 Department of Vascular and Endovascular Surgery, University Hospital Roskilde / Zealand University Hospital , Roskilde, Denmark MD, DMSc Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Saeid H. Shahidi Jose Ignacio Leal Lorenzo 53 Vascular Surgery and Interventional Radiology Unit, Clinica Universidad de Navarra , Madrid, Spain MD, PhD, RPVI, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Arkadiusz Jawien 54 Department of Vascular Surgery and Angiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun , Bydgoszcz, Poland MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Tilman Reiff 55 Department of Neurology, Neurovascular Study Center, University of Heidelberg , Heidelberg, Germany MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Laura Capoccia 56 Vascular and Endovascular Surgery Division, Department of Surgery, ‘F. Spaziani’ Hospital , Frosinone, Italy MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site José Fernandes e Fernandes 57 Cardiovascular Center (CCUL), Faculty of Medicine University of Lisbon , Lisbon, Portugal 58 Department of Vascular Surgery, Hospital da Luz Torres de Lisboa , Lisbon, Portugal MD, PhD, FACS, FRCS Eng, FESC, FEBVS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Piotr Musiałek 59 Department of Cardiac & Vascular Diseases, Jagiellonian University of Krakow , John Paul II Hospital, Krakow, Poland MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Victor S. Gurevich 60 Center of Atherosclerosis and Lipid Disorders, North-Western State University n.a. I.I. Mechnikov, St. Petersburg State University , St. Petersburg, Russia MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Matthew Blecha 61 Dicision of Vascular Surgery, Stritch School of Medicine, Loyola University Chicago , Chicago, IL, U.S.A. MD, FACS, RPVI Find this author on Google Scholar Find this author on PubMed Search for this author on this site Caitlin W. Hicks 6 Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, The John Hopkins University School of Medicine , Baltimore, MD, U.S.A. MD, MS, FACS, FAHA, DFSVS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Caitlin W. Hicks Young M. Erben 62 Division of Vascular and Endovascular Surgery, Mayo Clinic , Jacksonville, FL, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Mark F. Conrad 63 Department of Surgery, Division of Vascular and Endovascular Surgery, St. Elizabeth’s Medical Center, Boston Medical Center Health System , Brighton, MA, U.S.A. MD, MMSc, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mark F. Conrad Mahmoud B. Malas 64 Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego , San Diego, CA, U.S.A. 65 Center for Learning & Excellent in Vascular & Endovascular Research (CLEVER), University of California San Diego , La Jolla, CA, U.S.A. MD, MHS, RPVI, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sean P. Lyden 66 Department of Vascular Surgery, Cleveland Clinic , Cleveland, OH, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sean P. Lyden Seemant Chaturvedi 67 Department of Neurology and Stroke Program, University of Maryland School of Medicine , Baltimore, MD, U.S.A. MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Seemant Chaturvedi Marc L. Schermerhorn 68 Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA, U.S.A. MD, FACS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Andrew N. Nicolaides 69 Vascular Screening and Diagnostic Center , Nicosia, Cyprus 70 University of Nicosia Medical School , Nicosia, Cyprus 71 Department of Vascular Surgery, Imperial College , London, United Kingdom DSc, PhD, MS, FRCS, FRCSE Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Andrew N. Nicolaides Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Background The optimal management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis is controversial and includes intensive medical management (i.e., best medical therapy [BMT]) with/without an additional carotid revascularization procedure (i.e., 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 6 different clinical scenarios were identified involving patients with either AsxCS or SxCS. For each scenario, 5 treatment options were available: (i) BMT alone, (ii) BMT plus CEA, (iii) BMT plus TFCAS, (iv) BMT plus TCAR, or (v) BMT plus CEA/TFCAS/TCAR. 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 80-99% 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 co-morbidities (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 70-99% 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 U.S.-based participants varied from that of Europe-based respondents in some scenarios. Conclusions The present Delphi Consensus document showed that a “one-size-fits-all” approach is not appropriate for patients with either AsxCS or SxCS. Patients should be stratified according to their future stroke risk and should be treated accordingly. Introduction Despite the release of international guidelines by various professional Societies/Organizations (e.g., the Society for Vascular Surgery [SVS], 1 , 2 the European Society for Vascular Surgery (ESVS), 3 the American Heart Association/American Stroke Association 4 and the European Stroke Organization 5 ), there is still substantial controversy regarding the optimal management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid artery stenosis. Treatment options include intensive medical management (i.e., best medical therapy [BMT]) either alone or in combination with a carotid revascularization procedure, namely carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS) or TransCarotid Artery Revascularization (TCAR). Several factors contribute to the ongoing controversy regarding optimal management, including: Variability in physician/surgeon/interventionalist preferences based on individual expertise and/or availability of specific technologies (e.g., TCAR is currently not available in many countries outside the United States); 6 Differences in patient preferences, co-morbidities, anatomical or physiological characteristics and treatment expectations; 7 , 8 A lack of robust evidence to support strong guidelines recommendations for certain patient subgroups (e.g., women, racial and ethnic minorities, etc.), as these populations were under-represented in landmark randomized controlled trials (RCTs). 3 As a result, there is often considerable uncertainty about the optimal management of some AsxCS and SxCS patient subgroups. In addition, recent advances suggest that the classification of AsxCS patients based on the degree of carotid stenosis alone may not adequately reflect future stroke risk. 9 The aim of the present international, multispecialty, expert-based Delphi Consensus document was to address the various therapeutic options available for the management of AsxCS and SxCS patients in an attempt to reconcile the conflicting views. Methods An international, multispecialty, expert-based Delphi consensus document was prepared according to the Conducting and REporting DElphi Studies (CREDES) Checklist. 10 A total of 26 experts from the United States and 37 experts from Europe (Italy [n=11], Poland [n=4], Netherlands [n=3], United Kingdom [n=2], Russia [n=2], Greece [n=2], Slovenia [n=2], Portugal [n=2], Hungary [n=2], France [n=1], Denmark [n=1], Germany [n=1], Spain [n=1], Bosnia and Herzegovina [n=1], Ireland [n=1] and Cyprus [n=1]) were invited to participate. Overall, 22 of the 26 participants from the U.S. and 25 of the 37 participants from Europe were vascular surgeons. All invited participants had at least 10 years of clinical experience and proof of academic expertise in the management of patients with AsxCS and SxCS, as documented by a list of relevant publications on PubMed/MedLine. Six different clinical scenarios were identified ( Figure 1 ). For each clinical scenario, participants were asked to select the optimal therapeutic approach from the following five options: (a) BMT alone, (b) BMT plus CEA, (c) BMT plus TFCAS, (d) BMT plus TCAR, or (e) BMT plus CEA/TFCAS/TCAR. Option (e) indicated that any revascularization method (CEA, TFCAS or TCAR) could be appropriate for the specific clinical scenario depending on personal expertise and equipment availability. Download figure Open in new tab Figure 1. The 6 clinical scenarios included in the Delphi Consensus document In total, 3 rounds were conducted. Participants had 2 weeks to vote during each round and all voting was anonymous. Only the Delphi Consensus co-ordinator (K.I.P.) had access to individual participant responses. Consensus was defined as >70% agreement among participants on a given therapeutic option. During Round 1, certain issues with the clinical scenarios were identified and clarified. Participants were not informed of the group voting results until after Round 2. In Round 3, participants were asked to finalize their votes. Differences in responses to each question between U.S. and European participants were assessed using Fisher’s Exact Test. Simulated p-values based on 10,000 Monte Carlo replicates were used due to some cells in the contingency tables containing small or zero counts; Fisher’s test was selected over the chi-squared test to ensure valid inferences under these conditions. To quantify the magnitude and direction of association between geographic region (U.S.A. vs . Europe) and treatment preference for AsxCS and SxCS patients, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with continuity correction applied when necessary to account for zero-cell values. Fisher’s Exact Test was used to calculate p-values. A pooled analysis of the treatment recommendations for all asymptomatic patient scenarios and all symptomatic patient scenarios in the U.S. respondents versus the European respondents was conducted. There were 26 U.S. respondents and 37 European respondents to 3 asymptomatic and 3 symptomatic scenarios. Therefore, there were a total of 78 U.S. scenario responses versus 111 European scenario responses in both the symptomatic and asymptomatic scenarios. For this pooled analysis the BMT + TCAR response option was merged with the BMT + CEA/CAS/TCAR option as there were very few to no BMT + TCAR responses in several scenarios. Comparison of the frequency of each treatment selection in the U.S. cohort versus the European cohort of respondents was conducted with univariable OR analysis with resultant P-Values, ORs and 95% CIs. The first draft of the Delphi Consensus document was prepared by the co-ordinator and was circulated to all participants for feedback. The manuscript was revised twice based on their comments and suggestions. The final version of the manuscript was approved by all participants. Any potential conflicts of interest were disclosed and are listed at the end of the manuscript. Results All 63 participants completed all 3 voting rounds. Overall, 22 of 63 (34.9%) maintained the same responses from Round 1 to Round 3, while 18 of 63 (28.6%) changed their votes in at least one scenario between Round 1 and Round 2, but not from Round 2 to Round 3. The remaining 23 of 63 (36.5%) changed their votes to at least one scenario from Round 1 to Round 2 and again from Round 2 to Round 3. Although consensus on a specific carotid intervention was not achieved, only 11 of 63 (17.4%) participants opted for BMT alone in managing a 70-year-old fit (American Society of Anesthesiologists [ASA] Class II) 11 male patient with 80-99% AsxCS ( Table 1 ). Of these, 4 of 11 (36.3%) would initially choose BMT with plans to re-evaluate the patient with a follow-up ultrasound scan in 6 months to check for disease progression/regression. Furthermore, 7 of 11 (63.7%) would initiate BMT alone while also monitoring for clinical or imaging features suggesting ‘high-stroke’ risk on BMT alone as recommended by the 2023 ESVS guidelines. 3 View this table: View inline View popup Download powerpoint Table 1. What would you recommend to a 70-year-old fit male patient with 80-99% asymptomatic carotid stenosis (ASA Class II)? Similarly, only 18 of 63 (28.5%) participants selected BMT alone for the management of a 70-yea-old fit (ASA Class II) 11 female patient with 80-99% AsxCS ( Table 2 ). Of these, 8 of 18 (44.4%) opted for an initial BMT alone strategy with reassessment of the patient with a new ultrasound scan in 6 months to check for disease progression/regression. Additionally, 10 of 18 (55.6%) would initiate BMT alone but would also look for clinical/imaging features suggesting ‘high-stroke’ risk on BMT alone, as recommended by the 2023 ESVS guidelines. 3 In contrast, 48 of 63 (76.2%) panelists would only offer BMT alone to an 80-year-old male patient with 80-99% AsxCS and several comorbidities (ASA Class III), such as chronic obstructive pulmonary disease [COPD], previous myocardial infarction [MI] and/or coronary artery bypass grafting ( Table 3 ). View this table: View inline View popup Download powerpoint Table 2. What would you recommend to a 70-year-old fit female patient with 80-99% asymptomatic carotid stenosis (ASA Class II)? View this table: View inline View popup Download powerpoint Table 3. What would you recommend to an 80-year-old male patient with several comorbidities (COPD, past MI, CABG) and 80-99% asymptomatic carotid stenosis (ASA Class III)? When presented with the clinical scenario involving an 80-year-old symptomatic male patient with a recent transient ischemic attack (TIA) episode, an ipsilateral 70-99% SxCS, and a 5-year predicted risk of ipsilateral ischemic event using the carotid artery risk (CAR) score 12 of 10%, >80% of participants (54/63; 85.7%) would offer BMT plus an intervention ( Table 4 ). This intervention would be CEA or TCAR, but not TFCAS. When the same 80-year-old symptomatic male patient with a recent TIA episode and an ipsilateral 70-99% SxCS, had a 5-year predicted risk of ipsilateral ischemic event using the CAR score 12 of 15%, >90% of participants (59/63; 93.6%) would offer BMT plus an intervention ( Table 5 ), and if the same patient had a CAR score 12 of ≥20%, all participants (63/63; 100%) would offer BMT plus a carotid intervention ( Table 6 ). View this table: View inline View popup Download powerpoint Table 4. What would you recommend to an 80-year-old symptomatic male patient with a recent TIA, an ipsilateral 70-99% symptomatic carotid stenosis, and a 5-year predicted risk of ipsilateral ischemic stroke using the CAR score (CAR Score) of 10%? View this table: View inline View popup Download powerpoint Table 5. What would you recommend to an 80-year-old symptomatic male patient with a recent TIA, an ipsilateral 70-99% symptomatic carotid stenosis, and a 5-year predicted risk of ipsilateral ischemic stroke using the CAR score (CAR Score) of 15%? View this table: View inline View popup Download powerpoint Table 6. What would you recommend to an 80-year-old symptomatic male patient with a recent TIA, an ipsilateral 70-99% symptomatic carotid stenosis, and a 5-year predicted risk of ipsilateral ischemic stroke using the CAR score (CAR Score) of ≥20%? Comparative analysis between U.S.-based and Europe-based participants revealed some regional differences ( Supplementary Tables 1-6 ). European participants were more likely to opt for BMT alone in the management of a 70-year-old, fit male (21.6% vs . 11.5%, respectively; Supplementary Table 1 ) and female (35.1% vs . 19.2%, respectively; Supplementary Table 2 ) patients compared with their North American counterparts, but these differences were not significant. Most U.S. and European participants opted for BMT alone for the management of an 80-year-old male patient with several comorbidities (COPD, past MI, CABG) and 80-99% AsxCS (73.4% vs. 78.4%, respectively; p=0.3688; Supplementary Table 3 ). European participants favored BMT plus CEA as the optimal treatment option for an 80-year-old symptomatic male patient with a recent TIA, an ipsilateral 70-99% SxCS, and a 5-year predicted risk of ipsilateral ischemic stroke using the CAR score of 10% (48.6% vs . 42.4%, respectively; p=0.119), 15% (56.8% vs . 30.8%, respectively; p=0.0124) and 20% (59.5% vs . 30.8%, respectively; p=0.0032) compared with U.S. participants. In contrast, U.S. participants were more likely to offer CEA or TCAR (but not TFCAS) to these patients compared with European participants (42.4% vs . 16.3%, 61.6% vs . 21.6% and 65.4% vs . 14.3%, respectively; Supplementary Tables 4, 5 and 6 ). The three asymptomatic patient scenarios were pooled to allow for comparison of U.S. vs . European participant preferences. U.S.-based participants were significantly more likely than their European counterparts to opt for BMT plus CEA/CAS/TCAR (42.3 vs . 26.0%, respectively; OR: 4.251; 95% CI: 2.204-8.364, p<0.001; Supplementary Table 7 ). The BMT + TCAR option was merged into the BMT + CEA/TFCAS/TCAR cohort for this analysis due to low sample size on the BMT + TCAR option and the current minimal availability of TCAR in Europe. The three symptomatic patient scenarios were pooled to allow for comparison of U.S.-based vs . European participant preferences. U.S.-based participants were significantly more likely to opt for BMT plus CEA/CAS/TCAR in symptomatic patients (60.3% vs . 27.0%, respectively; OR: 4.060; 95% CI: 2.112-7.958; p<0.001). In contrast, U.S.-based participants were significantly less likely to opt for BMT + CEA or BMT + CAS than their European counterparts in treating SxCS (34.6 vs . 54.9%, respectively; OR: 0.436; 95% CI: 0.228-0.822; p=0.008; and 0 vs . 10.0%, respectively; OR: 0; 95% CI: 0-0.533; p=0.003; Supplementary Table 8 ). Once again, the BMT + TCAR option was merged into the BMT + CEA/TFCAS/TCAR cohort for this analysis due to low sample size on the BMT + TCAR option and the current minimal availability of TCAR in Europe. Discussion The present international, expert-based Delphi Consensus document revealed several findings regarding the optimal management of both AsxCS and SxCS patients. These findings are presented and discussed. AsxCS patients It is now well-recognized that not all AsxCS patients carry the same stroke risk. A 2014 opinion article emphasized the importance of identifying ‘high-risk’ AsxCS patients to selectively offer prophylactic carotid revascularization procedures to those most likely to benefit. 14 A number of clinical and imaging features have been proposed for stratifying stroke risk in this population, including: (1) the detection of microemboli on transcranial Doppler, identification of the unstable carotid plaque using ultrasound, (3) reduced cerebrovascular reserve, (4) identification of intraplaque hemorrhage on MRI, (5) progression in the stenosis severity, and, (6) a combination of multiple independent risk stratification parameters (e.g., baseline degree of stenosis, history of contralateral stroke or TIA, size of juxtaluminal plaque area ≥8 mm 2 without a visible echogenic cap and the presence of discrete white areas in a hypoechoic plaque, or a combination of a low gray scale median score with transcranial Doppler microembolic signals). 14 Based on these findings, the 2017 ESVS carotid guidelines recommended that for patients with 60-99% AsxCS and 1 or more of these ‘high-risk’ clinical/imaging features associated with an increased risk for late stroke on BMT alone, 14 CEA should be considered (Class IIa; Level of Evidence: B) or TFCAS may be considered (Class IIb; Level of Evidence: B) for the reduction of long-term risk of stroke, provided that anatomy is favorable, 30-day stroke/death rates are ≤3% and the patient’s life-expectancy exceeds 5 years. 15 These recommendations remained unchanged in the recently updated 2023 ESVS carotid guidelines. 3 Similarly, the 2022 SVS carotid guidelines endorse the use of CEA, TCAR or TFCAS in patients with ≥70% AsxCS, provided that the patient has at least a 3-to 5-year life expectancy and perioperative stroke/death rates can be ≤3%. 1 , 2 The SVS Guidelines emphasized that selection of the revascularization strategy should be based on the presence or absence of specific high-risk anatomic criteria for each procedure. 1 , 2 For instance, the presence of a tracheal stoma or a lesion above C2 would be a contraindication for CEA. 1 , 2 In contrast, a distance to the carotid bifurcation <5 cm or a common carotid artery diameter <6 mm would be a contraindication for TCAR. 1 , 2 Finally, a tortuous common or internal carotid artery would be a contraindication for TFCAS. 1 , 2 In addition, the SVS carotid guidelines clearly indicated that lesion morphology such as echolucency, calcification, long irregular plaques, the presence of fresh thrombus or a string sign can affect outcomes and may alter decision-making concerning the optimal carotid revascularization procedure. 1 , 2 Therefore, the choice of the optimal therapeutic modality would depend on the presence or absence of such high-risk anatomic criteria and lesion morphology. 1 , 2 Finally, it was specified that physiologic comorbidities such as congestive heart failure, left ventricular ejection fraction ≤35%, unstable angina, the presence of MI within the past 6 weeks COPD and renal failure constitute considerable physiologic risks, and in such patients, TCAR is preferred over CEA and TFCAS. 2 Recent evidence suggests that the degree/percentage of AsxCS alone is not an adequate predictor of future ipsilateral ischemic stroke risk. Several other parameters have been proposed to more accurately stratify AsxCS patients with regards to future stroke risk. Examples include the type of carotid plaque, 13 or a high carotid plaque-reporting and data system score (RADS). 9 These parameters may be more accurate predictors of future ipsilateral ischemic stroke risk and should probably be implemented in future guidelines to guide the identification of ‘high-risk’ AsxCS individuals for whom a prophylactic carotid intervention is warranted in addition to BMT. Identification of prognostic factors for long-term survival in AsxCS patients and risk prediction models for the development of a future stroke in these individuals, as well as the development of valid and reliable stroke risk stratification models/systems are crucial to select those asymptomatic patient subgroups most likely to benefit from a prophylactic carotid intervention. 16 – 20 SxCS patients Both the 2022 SVS and the 2023 ESVS carotid guidelines strongly recommend carotid revascularization within 14 days of an ischemic cerebrovascular in patients with and an ipsilateral 50-99% SxCS. 1 – 3 In this scenario, both guidelines advocate for CEA over TFCAS, based on evidence supporting superior safety and efficacy in these patients. 1 – 3 Additionally, the SVS guidelines highlight data from large national registries suggesting that in symptomatic patients, TCAR is associated with lower stroke/death rates than TFCAS and demonstrates comparable outcomes with CEA. 2 However, it is important to note that the vast majority of TCAR procedures to date have been performed in patients considered high risk for CEA due to anatomic or medical factors. While early results are encouraging, further data in low-risk symptomatic patients are needed to validate these findings. 2 A few months ago, Dermody (Penn Medicine Lancaster, U.S.A.) presented at VIVA 2024 Meeting in Las Vegas the early data on TCAR from the ROADSTER 3 trial. 21 This is an FDA post-approval study of the first prospective multicenter trial evaluating the safety and efficacy of TCAR using the Silk Road Enroute transcarotid stent system in conjuction with its Enroute transcarotid neuroprotection system for the treatment of carotid stenosis in standard surgical risk patients. 21 ROADSTER 3 enrolled 344 patients at 53 U.S. sites for intention-to-treat (ITT) analyses. The single arm study primary end-point was a composite of major adverse events of stroke, death and MI through 30 days post-procedure and ipsiliateral strokes from day 31 to 365 post-procedure. Approximately 75% of patients were younger than 75 years of age, 43% were female and 16% had SxCS. The mean lesion length was 23 mm and 17% of the lesions had severe calcification. The 30-day rate of stroke/death/MI in the study’s ITT population was 0.9%, which decreased to 0.6% within per-protocol analysis involving 320 patients. The incidence of cranial nerve injury within 30 days was 0.6% and all cranial nerve deficits resolved within 6 months. 21 It was concluded that since TCAR is less invasive than CEA and has similar stroke rates with a lower incidence of cranial nerve injury, if a patient is able to take dual antiplatelet and statin therapy and has anatomy that is amenable to TCAR, then TCAR should be the first-choice modality. 21 Recently, the 2-year interim results of the 2nd European Carotid Surgery Trial (ECST-2) were published. 22 ECST-2 was an international, multicenter (n=30), open-label, non-inferiority randomized controlled trial conducted at sites in Europe and Canada. 22 The trial tested whether patients with ≥50% AsxCS or SxCS with a low-to-intermediate predicted risk of stroke receiving BMT would benefit from additional revascularization. 22 The primary end-point for the 2-year analysis was a ‘hierarchical’ composite outcome consisting of: (1) periprocedural death, fatal stroke, or fatal MI; (2) non-fatal stroke; (3) non-fatal MI; or (4) new silent cerebral infarction on imaging. 22 The interim analysis found no significant difference in the ‘hierarchical’ outcome between treatment groups. 22 It was therefore concluded that ‘ no evidence for a benefit of revascularization in addition to BMT was found in the first 2 years following treatment for patients with asymptomatic or symptomatic carotid stenosis of 50% or greater with a low or intermediate predicted stroke risk (assessed by the CAR score)’ . 22 They further recommended that ‘ patients with asymptomatic and low or intermediate risk symptomatic carotid stenosis should be treated with BMT alone until further data from the 5-year analysis of ECST-2 and other trials become available’ . 22 Although ECST-2 was an exemplary RCT, its findings raise some concerns. Notably, the composite outcome of periprocedural death, stroke, or MI, was 10.2% in the BMT alone group compared to 10.5% in the BMT plus revascularization group (hazard ratio: 0.92; 95% CI: 0.51-1.67; p=0.46). 22 Given that the 2-year MI rate in the BMT plus revascularization group was 2.5%, this implies a periprocedural death/stroke rate of ≥8.0%. 22 Both the 2022 SVS 1 , 2 and the 2023 ESVS 3 clearly state the periprocedural stroke and death rates should be ≤3% in AsxCS and ≤6% in SxCS patients to justify revascularization. Accordingly, the periprocedural death, stroke or MI rates reported for the BMT plus carotid revascularization group in ECST-2 22 are alarmingly high and exceed the recommended safety thresholds endorsed by both the SVS and the ESVS guidelines, for patients with either AsxCS or SxCS undergoing a carotid intervention. ECST-2 22 had several flaws/limitations: Although a sample size of 2,000 patients was initially calculated, 23 at the end only 428 patients were randomized to BMT alone (n=214) or BMT plus revascularization (n=214), 22 which is an extremely small sample to predict major cerebrovascular events. Both symptomatic (40%) and asymptomatic (60%) patients were included, and even within the symptomatic patients, only those at low/intermediate risk based on CAR scoring were considered. Among the asymptomatic patients, 47 of 129 (36.5%) in the BMT group and 48 of 129 (37.2%) in the BMT plus revascularization group had AsxCS ≤69%. 22 It would be interesting to know why nearly 1 for every 4 asymptomatic patients in the BMT plus revascularization group (48 of 214; 22.5%) was offered an intervention for a ≤69% AsxCS. 22 Among the 214 patients allocated to BMT alone, 22 (10%) eventually underwent an ipsilateral carotid revascularization procedure. 22 These flaws/limitations suggest that long-term data and a bigger sample size is needed before we consider the conclusions of this study. Although guidelines provide recommendations for patients at ‘average surgical risk’, the management may differ in those deemed ‘high-risk’ due to medical comorbidities. In AsxCS patients, for example, life expectancy of >5 years and low perioperative complications are prerequisites to reliably achieving benefit from a carotid intervention. 1 – 3 Furthermore, a systematic review of outcomes in 21 registries (>1,500,000 patients) showed that stroke and death rates after TFCAS often exceed the recommended thresholds by the AHA/ASA (<3% for AsxCS; <6% for SxCS). 24 More nuanced stroke risk stratification tools such as the carotid plaque-RADS classification system 9 or various plaque features (e.g., ulceration, thin fibrous cap, juxtaluminal black area >8mm 2 ), 13 and patient-specific anatomical and physiological characteristics may help identify which individuals would benefit most from either BMT alone or BMT plus carotid revascularization. The differences between participants from the U.S. and their European counterparts in the pooled analysis probably reflect the availability and increased utilization of TCAR in the United States. TCAR offers a less invasive carotid revascularization option than CEA with similar perioperative stroke rates when applied to patients with anatomy appropriate for TCAR. 25 TCAR is therefore viewed in the U.S. as a viable and potentially superior option to CAS and CEA in patients at higher surgical risk due to medical comorbidities or due to anatomically hostile necks. The present Delphi Consensus document has some limitations. As with all Delphi Consensus documents, a different composition of the panel (e.g., more interventional radiologists/cardiologists, fewer vascular surgeons, more U.S. participants, etc.) could have produced different results. In addition, the decision-making for each patient would also take into account individual anatomical and physiological characteristics/risk factors that would make them high-risk for specific procedures (e.g., anatomy suitable for the selected procedure, patient life expectancy, type of carotid plaque, etc.). Furthermore, no information was provided regarding the type of plaque (e.g., the presence of carotid ulcer, a thin fibrous cap, discrete white areas or large a juxtaluminal black area [>8 mm 2 ]) or the brain CT findings (e.g., the presence of silent ipsilateral infarcts). For example, there is evidence that intraplaque hemorrhage and plaque ulceration are more likely in patients with mild-to-moderate SxCS than in high-grade AsxCS/SxCS. 26 Such information could alter the votes of many of the participants. Finally, the Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis (CREST-2) 27 study is on-going. Its results may alter the opinion of some of the participants of this Delphi Consensus. Conclusions In conclusion, this international, multi-specialty Delphi Consensus Document highlights the ongoing variability in the management of both SxCS and AsxCS patients. Although consensus was not achieved in all scenarios – particularly regarding the preferred revascularization technique – these differences largely reflect the diverse expertise, geographic practice patterns, and resource availability among panel participants. Notably, 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. These findings support the importance of personalized stroke risk stratification, incorporating clinical, anatomical, and imaging features to guide decisions about whether and how to intervene. As emerging data – such as from ECST-2 22 and CREST-2 27 – continue to shape the evidence base, interdisciplinary dialogue and individualized decision-making will remain critical in optimizing outcomes for patients with both AsxCS and SxCS. Data Availability All data is available by Dr. Kosmas I. Paraskevas Conflicts of interest Dr. Michael C. Stoner has a Consultant agreement with Boston Scientific. Dr. Mahmoud B. Malas is a Consultant to Cordis and Bard. Dr. Peter A. Schneider is a Consultant to Surmodics, Medtronic, Boston Scientific, Cagent, Acotec, Abbott, Endologix, Shockwave, Healthcare Inroads, Inari and BD. Dr. Mark K. Eskandari is a paid consultant for W.L. Gore and Silkroad Medical (Boston Scientific). Dr. Meghan Dermody is a Consultant/speaker for Boston Scientific Vascular and Medtronic Aortic. Dr. Marc L. Schermerhorn is PI for Medtronic, Boston Scientific and Shape clinical trials. He also does research with Cook, Terumo and Gore. Dr. Gary Roubin is the Chair of the Interventional Management Committee of CREST-2. He is also InspireMD Inc. Director and stock holder. Dr. Sean P. Lyden is a Consultant for BD, Boston Scientific, Contego Medical, Cordis, Endologix, Inspire MD, Medtronic, Rapid Medical, Shockwave, Penumbra, Vivasure and Nectero. 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Nicolaides medRxiv 2025.08.01.25332713; doi: https://doi.org/10.1101/2025.08.01.25332713 Share This Article: Copy Citation Tools 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 , Ali F. AbuRahma , Wesley S. Moore , Peter Gloviczki , Bruce A. Perler , Daniel G. Clair , Christopher J. White , Carlo Setacci , Eric A. Secemsky , Peter A. Schneider , Clark J.A.M. Zeebregts , Armando Mansilha , Luca Saba , Ian M. Loftus , Jeffrey Jim , Christos D. Liapis , Vincenzo Di Lazzaro , Alan Dardik , Pavel Poredos , Ankur Thapar , Salvatore T. Scali , Mario D’Oria , Ales Blinc , Alexei Svetlikov , David H. Stone , Sherif A.H. Sultan , Deniz Bulja , Michael C. Stoner , Piotr Myrcha , Maarten Uyttenboogaart , Mark A. Farber , Gianluca Faggioli , Domenica Crupi , Csaba Csobay-Novak , Jens Eldrup-Jorgensen , Gaetano Lanza , Gert J. de Borst , Francesco Stilo , Meghan Dermody , Mauro Silvestrini , Christopher J. Abularrage , Guillaume Goudot , Robert M. Proczka , Gary S. Roubin , Francesco Spinelli , Gabor Menyhei , Saeid H. Shahidi , Jose Ignacio Leal Lorenzo , Arkadiusz Jawien , Tilman Reiff , Laura Capoccia , José Fernandes e Fernandes , Piotr Musiałek , Victor S. Gurevich , Matthew Blecha , Caitlin W. Hicks , Young M. Erben , Mark F. Conrad , Mahmoud B. Malas , Sean P. Lyden , Seemant Chaturvedi , Marc L. Schermerhorn , Andrew N. 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