Current status of carotid bifurcation angioplasty and stenting based on a consensus of opinion leaders

Objective: Carotid bifurcation angioplasty and stenting (CBAS) has generate d controversy and widely divergent opinions about its current therapeutic r ole. To resolve differences and establish a unified view of CBAS' present r ole, a consensus conference of 17 experts, world opinion leaders from five countries, was held on November 21, 1999. Methods: These 17 participants had previously answered 18 key questions on current CBAS issues. At the conference these 18 questions and participants' answers were discussed and in some cases modified to determine points of a greement (consensus), near consensus, (prevailing opinion), or divided opin ion (disagreement). Results: Conference discussion added two modified questions, placing a tota l of 20 key questions before the participants, representing four specialtie s (interventional radiology, seven; vascular surgery, six; interventional c ardiology, three; neurosurgery, one). It is interesting that consensus was reached on the answers to 11 (55%) of 20 of the questions, and near consens us was reached on answers to 6 (30%) of 20 of the questions. Only with the answers to three (15%) of the questions was there persisting controversy. M oreover, both these differences and areas of agreement crossed specialty li nes. Consensus Conclusions: CBAS should not currently undergo widespread practic e, which should await results of randomized trials. CBAS is currently appro priate treatment for patients at high risk in experienced centers. CBAS is not generally appropriate for patients at low risk. Neurorescue skills shou ld be available if CBAS is performed. When cerebral protection devices are available, they should be used for CBAS. Adequate stents and technology for performing CBAS currently exist. There were divergent opinions regarding t he proportions of patients presently acceptable for CBAS treatment (<5% to 100%, mean 44%) and best treated by CBAS (<3% to 100%, mean 34%). These and other consensus conclusions will help physicians in all specialties deal w ith CBAS in a rational way rather than by being guided by unsubstantiated c laims.