The 2024 European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms: Cutting Edge or Just Another Update?

Since the publication of the 2011 and 2019 guidelines on abdominal aortic aneurysm (AAA) management, various important events have occurred. We have been through a pandemic, and the National Institute for Health and Care Excellence (NICE) guidelines were published after a long debate and controversies within the UK.1Hinchliffe R.J. Earnshaw J.J. Endovascular treatment of abdominal aortic aneurysm: a NICE U-turn.Br J Surg. 2020; 107: 940-942Crossref PubMed Scopus (13) Google Scholar Despite these challenging circumstances, the guideline writing committee (GWC) has been able to renew and update the previous guidance.2Wanhainen A. Van Herzeel I. Bastos Goncalves F. Bellmunt Montoya S. Berard X. Boyle J.R. et al.Editor's Choice – European Society for Vascular Surgery (ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2024; 67: 192-331Abstract Full Text Full Text PDF PubMed Google Scholar This is a particularly useful document to help offer patients with an aneurysm the best possible evidence based care. The GWC of the 2024 guidelines should be congratulated for this update. There were many important topics to focus on and guidelines to renew in order to help physicians and patients achieve the best outcomes from the care provided. Challenging topics were the decreasing prevalence of AAA in screening programmes, centralisation and volume–outcomes regarding treatment of AAA, surveillance after endovascular aneurysm repair (EVAR), the need for guidance during the shared decision making (SDM) process, and guidance on training. Furthermore, since the rapid evolution and introduction of large language models and artificial intelligence, guidance on these topics will be needed in the next iteration of this document.3Lareyre F. Raffort J. Ethical concerns regarding the use of large language models in healthcare.EJVES Vasc Forum. 2023; 61: 1PubMed Google Scholar The majority of recommendations have undergone thorough review by the GWC, illustrating the commitment to evidence based practice. There are 59 completely new recommendations and 49 recommendations have been updated based on 474 new references published since the publication of the former version of the guidelines. Nevertheless, only 5% of the recommendations are based on Level A evidence, highlighting the need for more robust evidence and further research. Still, the GWC has been able to generate evidence based guidelines, which are vital to our field and day to day practice, despite these difficulties with research gaps. In comparison, in the 2023 European Society of Cardiology (ESC) guidelines for acute coronary syndrome, 55% of the recommendations are based on Level A evidence. The GWC has developed a core outcome set for abdominal aneurysm repair for two reasons. First, to improve systematic review of evidence allowing for better comparisons across studies, including registries, prospective and retrospective studies, and randomised clinical trials. Second, to enhance patient centred care, including patient reported outcome measures (PROMs). Randomised controlled trials demonstrated the effectiveness of screening to reduce AAA specific mortality more than a decade ago. Since then, the prevalence has clearly decreased from 2.2% to only 0.9% in current screening programmes.4Svensjö S. Björck M. Gürtelschmid M. Djavani Gidlund K. Hellberg A. Wanheinen A. Low prevalence of abdominal aortic aneurysm among 65-year-old Swedish men indicates a change in the epidemiology of the disease.Circulation. 2011; 124: 1118-1123Crossref PubMed Scopus (378) Google Scholar,5Public Health EnglandAAA standards report 2019 to 2020.https://www.gov.uk/government/statistics/abdominal-aortic-aneurysm-screening-standards-report-2019-to-2020/aaa-standards-report-2019-to-2020Date accessed: December 22, 2023Google Scholar The GWC has attempted to identify high risk groups who might benefit from screening, however this is only supported by retrospective studies or post hoc analyses of randomised trials. Therefore, using the disclaimer that it is probably due to variations within the local treating regions and refraining from specifying the target population is helpful. This will require further research to identify these high risk groups that might benefit from targeted screening.6Chiew K. Roy I.N. Budge J. D'Abate F. Holt P. Loftus I.M. The fate of patients opportunistically screened for abdominal aortic aneurysms during echocardiogram or arterial duplex scans.Eur J Vasc Endovasc Surg. 2023; 66: 188-193Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Since the association between annual procedural volume and peri-operative mortality has been established in aortic surgery, the scope of our field has changed remarkably. While the mortality rate following straightforward endovascular procedures is relatively low, the volume–outcome association will be more apparent in open and complex endovascular procedures.7Scali S. Wanhainen A. Neal D. Debus S. Mani K. Behrendt C.A. et al.Conflicting European and North American society abdominal aortic aneurysm (AAA) volume guidelines differentially discriminate peri-operative mortality after elective open AAA repair.Eur J Vasc Endovasc Surg. 2023; 66: 756-764Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar,8Alberga A.J. von Meijenfeldt G.C.I. Rastogi V. de Bruin J.L. Wever J.J. van Herwaarden J.A. et al.Association of hospital volume with perioperative mortality of endovascular repair of complex aortic aneurysms: a nationwide cohort study.Ann Surg. 2023; 277: e678-e688Crossref Scopus (14) Google Scholar The need for a further specification for a minimum caseload of open aneurysm repair is therefore evident. Despite the often described benefits, this subject still brings up heated discussions, as many consider this subject highly controversial. Identifying strict cutoff values is difficult but necessary to drive centralisation and further improvement of peri-operative outcomes. It is therefore to be saluted that the GWC extended the recommendations regarding this subject. The recommended minimum yearly caseload has been upgraded to ≥ 30 standard AAA repairs per centre, with a specific minimum of 15 each of open and endovascular repair. Furthermore, a consensus recommendation was added on a minimum yearly caseload of > 20 combined open and fenestrated and branched endovascular repairs for complex AAAs. The use of validated prospective registries remains vital to substantiate those changes needed. Furthermore, the quality of vascular surgery cannot be improved solely by the volume–outcome association and requires ongoing monitoring. Surveillance after EVAR remains a controversial subject, with an increasing number of papers questioning its usefulness for improved survival. In the 2019 version of the European Society for Vascular Surgery (ESVS) guidelines, a proposal was made to safely reduce outpatient visits and follow up scans. That proposal unfortunately does not seem to have led to a clear change in clinical practice, possibly due to lack of (trust in) clear evidence on its safety and efficacy. The new guidelines on follow up after EVAR have been updated to ensure best management practices, with an emphasis on monitoring graft performance and identifying complications. This includes a novel (updated) algorithm to identify low risk patients who will require fewer scans and follow up. In this algorithm, in contrast to the former proposal, a proximal neck diameter > 30 mm, proximal neck angulation > 60°, and iliac diameter > 20 mm have been added as high risk features. Further evidence, specifically on this new algorithm, is needed as to whether we can safely postpone surveillance for a proportion of low risk patients after EVAR. Long term clinical success of EVAR beyond five years remains under studied, therefore long term imaging follow up for all EVAR patients is advised by the GWC. Thus far, no specific guideline has been implemented for complex endovascular procedures, and the GWC has proposed a more individualised follow up in these patients based on the device and perceived risk of late failure. The evidence regarding EVAR surveillance is very heterogeneous and is known as the surveillance paradox, including similar survival and re-intervention rates in patients compliant and non-compliant with follow up after EVAR.9Antoniou G.A. Kontopodis N. Rogers S.K. Golledge J. Forbes T.L. Torella F. et al.Editor's Choice – Meta-analysis of compliance with endovascular aneurysm repair surveillance: the EVAR surveillance paradox.Eur J Vasc Endovasc Surg. 2023; 65: 244-254Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar A robust trial or prospective evidence identifying optimum and cost effective follow up protocols both after EVAR and complex EVAR is clearly needed, especially in low risk patients. An important addition to the new guidelines is the inclusion of quality of life and PROMs. This information is essential in the SDM process when discussing the pros and cons of different treatment options, especially as most of the interventions described are purely elective in completely asymptomatic patients. For this, a new core outcome set was developed with stakeholders and patients, consisting of six patient related outcome measures including short and long term mortality rate as well as quality of life and retention of cognitive function. Some of these outcomes still lack validated measurement tools and are therefore not easy to obtain. This should be seen as a call to us all to quickly develop such tools. Elective aneurysm procedures are well suited to implement the SDM process and are part of patient centred care, which should guide the treatment of patients with an AAA. The GWC has developed new guidance and included a chapter on information for patients to facilitate the SDM process, including two recommendations on the matter.2Wanhainen A. Van Herzeel I. Bastos Goncalves F. Bellmunt Montoya S. Berard X. Boyle J.R. et al.Editor's Choice – European Society for Vascular Surgery (ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2024; 67: 192-331Abstract Full Text Full Text PDF PubMed Google Scholar Most patients want to be involved however they do not receive adequate information.10Machin M. Van Herzeele I. Ubbink D. Powell J.T. Shared decision making and the management of intact abdominal aortic aneurysm: a scoping review of the literature.Eur J Vasc Endovasc Surg. 2023; 65: 839-849Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Especially during the first drafts of the NICE guidance, patient preference was left out and the main focus was on cost effectiveness. In the final version of the NICE guidelines, it was established that patient centred care was important and this changed the recommendations completely, recognising the need for minimally invasive procedures and patient centred care.1Hinchliffe R.J. Earnshaw J.J. Endovascular treatment of abdominal aortic aneurysm: a NICE U-turn.Br J Surg. 2020; 107: 940-942Crossref PubMed Scopus (13) Google Scholar In conclusion, the new 2024 ESVS clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms are an impressive gathering of all the available contemporary evidence and therefore form the basis of most important treatment decisions. Implementation of these guidelines will support clinicians and improve patient outcomes. H.J.M.V. is a consultant for Medtronic, W.L. Gore, Cook, Artivion, Endologix, Terumo Aortic, and Philips. J.L.B. declares no conflicts of interest. No funding was provided.