EDITORIAL
The 2019 update of the European abdominal aortic
aneurysm guidelines
Ronald L. Dalman, MD, Stanford, Calif
The updated 2019 European Society for Vascular
Surgery (ESVS) guidelines add welcome context and
perspective to management of the patient with abdom-
inal aortic aneurysm (AAA) disease. 1 This document,
replacing the original 2011 European compilation,
refreshes recommendations in existing topic categories
and includes new guidance on quality standards, institu-
tional resource requirements, and minimal surgical
volumes believed to be necessary to provide adequate
AAA care as well as specific disease subtypes (juxtarenal,
mycotic, inflammatory, syndromic, saccular) not previ-
ously considered separately. Therapeutic approaches
not available or included in the 2011 edition (fenestrated
endovascular grafting, parallel grafts, aneurysm sealing,
and endostapling) are also incorporated.
Not surprisingly, the scope and conclusions of the
current European guidelines, encompassing 125 specific
recommendations derived from nearly 800 references,
weighted using the European Society of Cardiology
grading system,2 are substantially similar to the updated
Society for Vascular Surgery (SVS) AAA guidelines (111
guidelines, 774 references) published January 2018. 3
This concordance reflects in part the similar systematic
literature review processes used to inform both writing
groups and their respective recommendations. 4 Differ-
ences with the 2018 SVS document, when they do exist,
mostly reflect the cultural and medical system heteroge-
neity of the multinational European Union as well as the
16 months of more recent evidence (through January
2018) included in the ESVS version.
In several important aspects, ESVS guidance is less
granular than that provided by the SVS; when recom-
mending medical therapy (eg, anticoagulation or antibi-
otics), the ESVS guidelines writing committee (GWC) did
not specify agents or dosing regimens. Heightened
specificity is provided, however, regarding systems of
From the Division of Vascular Surgery, Department of Surgery, Stanford
Medicine.
Author conflict of interest: none.
Correspondence: Ronald L. Dalman, MD, Alway M121N, Mail Code 5639, 300
Pasteur Dr, Stanford, CA 94305 (e-mail: rld@stanford.edu).
The editors and reviewers of this article have no relevant financial relationships to
disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
J Vasc Surg 2019;69:633-4
0741-5214
Copyright © 2018 Published by Elsevier Inc. on behalf of the Society for Vascular
Surgery.
https://doi.org/10.1016/j.jvs.2018.12.008
care; unlike their North American colleagues, the ESVS
GWC defined a maximal acceptable waiting time for
elective AAA repair following the decision to treat, a
recommendation necessitated in part by the population
health funding priorities of many European health care
systems. Similarly, all European centers offering AAA sur-
gical care are now expected to provide 24/7 access to
both open and endovascular repair options.
Current SVS guidelines not reflected in the 2019 ESVS
update include recommendations incorporating patient-
specific risk calculators in the process of informed
consent for surgery as well as time- dependent
management algorithms for care of the patient with a
ruptured AAA. In declining to endorse personalized
surgical risk calculators, the ESVS GWC thought that
the level of supporting evidence did not justify a
standard of care expectation (personal commu-
nication). Implementation of “door-to-balloon time”
equivalents for ruptured AAA management was consid-
ered unrealistic, especially considering that many Euro-
pean hospitals still provide endovascular aneurysm
repair only during business hours regardless of anatomic
suitability.
The ESVS guidelines derive some additional value from
their immediacy; literature review was extended through
January 2018 in the current document vs September
2016 in the 2018 SVS guidelines. As a result, the ESVS
document can emphasize the value of AAA screening
in reducing both disease-specific and all-cause mortality,
take a more nuanced approach to recommended
follow-up intervals after endovascular or open surgical
repair, and raise caution regarding the integration of
new technology (specifically endovascular aneurysm
sealing) into unrestricted clinical practice (among other
recommendations). Surprisingly, however, contempora-
neous observations regarding deleterious impact of
large-diameter aortic and iliac landing zones on stan-
dard endovascular aneurysm repair durability, even
when devices are deployed within their respective
instructions for use, were not recognized or incorporated
in the 2019 ESVS guidelines. 5,6 Before completing their
review, the ESVS GWC reviewed the 2018 SVS guidelines
to ensure that discrepancies between the documents,
when identified, were justified by most recent evidence
(personal communication).
Lesser differences exist in both style and content. The
SVS document, written more in the style of a book chap-
ter, abstracts and summarizes all of its updated recom-
mendations in the first section, whereas the ESVS
633
634 Dalman
approach leaves each embedded in its supporting text
with references attached. The ESVS document includes
for the first time unique patient-specific content devel-
oped with input from a panel of AAA patient volunteers.
Neither document addresses chronic gaps in implemen-
tation science that have limited the full impact of prior
iterations, although the SVS Patient Safety Organization
is incorporating relevant (and measurable) SVS
guideline-derived process and outcome metrics into
updated data fields for the Vascular Quality Initiative on-
line AAA data registry for participating centers in 2019.
Moving forward, the advisability of region-specific AAA
guidelines vs a consensus framework modeled after the
pending “global” chronic limb-threatening ischemia
document deserves further consideration. The common-
alities between the ESVS and SVS AAA guidelines far
outweigh the minor style, context, and implementation
differences noted. Discussions should begin now be-
tween respective national and regional professional soci-
eties and other stakeholders regarding the suitability of a
global framework for future AAA guidelines as modern
telecommunications, standards of living, and patient
expectations continue to converge worldwide. Vascular
patients, regardless of where they live, deserve quality
AAA care, and evidence-based consensus guidelines
are the most effective tool available to advance that goal.
Journal of Vascular Surgery
March 2019
REFERENCES
1. Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M,
Cohnert T, et al. European Society for Vascular Surgery (ESVS)
2019 Clinical Practice Guidelines on the Management of
Abdominal Aorto-iliac Artery Aneurysms [published online
ahead of print December 5, 2018]. Eur J Vasc Endovasc Surg
doi: 10.1016/j.ejvs.2018.09.020.
2. Committee for Practice Guidelines (CPG) of the European
Society of Cardiology. Recommendations for Guidelines Pro-
duction: a document for Task Force Members responsible for
the Production and Updating of ESC Guidelines. Available at:
https://escardio.org/static_file/Escardio/Guidelines/About/
Recommendations-Guidelines-Production.pdf. Accessed
December 20, 2018.
3. Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA,
Mansour MA, et al. The Society for Vascular Surgery practice
guidelines on the care of patients with an abdominal aortic
aneurysm. J Vasc Surg 2018;67:1-75.
4. Kredo T, Bernhardsson S, Machingaidze S, Young T, Louw Q,
Ochodo E, et al. Guide to clinical practice guidelines: the
current state of play. Int J Qual Health Care 2016;28:122-8.
5. Oliveira NF, Bastos Goncalves FM, Van Rijn MJ, de Ruiter Q,
Hoeks S, de Vries JP, et al. Standard endovascular aneurysm
repair in patients with wide infrarenal aneurysm necks is
associated with increased risks of adverse events. J Vasc Surg
2017;65:1608-16.
6. Gray D, Shahverdyan R, Reifferscheid V, Gawenda M,
Brunkwall JS. EVAR with flared limbs has a high risk of late
type 1b endoleak. Eur J Vasc Endovasc Surg 2017;54:170-6.
Submitted Dec 19, 2018; accepted Dec 19, 2018.