Publications
476 results found
Nicola M, Powell JT, 2024, Stop Smoking, Keep Walking, and Keep Taking the Antiplatelet Drugs Before Abdominal Aortic Aneurysm Repair., Eur J Vasc Endovasc Surg
Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al., 2024, 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, Vol: 67, Pages: 192-331
OBJECTIVE: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS: The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS: A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.
Zlatanovic P, Powell J, 2024, Medical Disinformation is Bad for Your Health., Eur J Vasc Endovasc Surg
Kawai K, Finn AV, Virmani R, et al., 2024, Subclinical Atherosclerosis: Part 1: What Is it? Can it Be Defined at the Histological Level?, Arterioscler Thromb Vasc Biol, Vol: 44, Pages: 12-23
While coronary artery disease remains a major cause of death, it is preventable. Therefore, the focus needs to shift to the early detection and prevention of atherosclerosis. Asymptomatic atherosclerosis is widely termed subclinical atherosclerosis, which is an early indicator of atherosclerotic burden, and understanding this disease is important because timely intervention could prevent future cardiovascular morbidity and mortality. We histologically recognize the earliest lesion of atherosclerosis as pathological intimal thickening, which is characterized by the presence of lipid pools. The difference between clinical atherosclerosis and subclinical atherosclerosis is whether the presence of atherosclerosis results in the clinical symptoms of ischemia, such as stroke, myocardial infarction, or chronic limb-threatening ischemia. In the absence of thrombosis, there are various types of histological plaque that encompass subclinical atherosclerosis: pathological intimal thickening, fibroatheroma, thin-cap fibroatheroma, plaque rupture, healed plaque ruptures, and fibrocalcific plaque. Plaque morphology that is most frequently responsible for acute coronary thrombosis is plaque rupture. Calcification of coronary arteries is the hallmark of atherosclerosis and is a predictor of future coronary events. Atherosclerosis occurs in other vascular beds and is most frequent in arteries of the lower extremity, followed by carotid, aorta, and coronary arteries, and the mechanisms leading to clinical symptoms are unique for each location.
Garg PK, Bhatia HS, Allen TS, et al., 2024, Assessment of Subclinical Atherosclerosis in Asymptomatic People In Vivo: Measurements Suitable for Biomarker and Mendelian Randomization Studies., Arterioscler Thromb Vasc Biol, Vol: 44, Pages: 24-47
BACKGROUND: One strategy to reduce the burden of cardiovascular disease is the early detection and treatment of atherosclerosis. This has led to significant interest in studies of subclinical atherosclerosis, using different phenotypes, not all of which are accurate reflections of the presence of asymptomatic atherosclerotic plaques. The aim of part 2 of this series is to provide a review of the existing literature on purported measures of subclinical disease and recommendations concerning which tests may be appropriate in the prevention of incident cardiovascular disease. METHODS: We conducted a critical review of measurements used to infer the presence of subclinical atherosclerosis in the major conduit arteries and focused on the predictive value of these tests for future cardiovascular events, independent of conventional cardiovascular risk factors, in asymptomatic people. The emphasis was on studies with >10 000 person-years of follow-up, with meta-analysis of results reporting adjusted hazard ratios (HRs) with 95% CIs. The arterial territories were limited to carotid, coronary, aorta, and lower limb arteries. RESULTS: In the carotid arteries, the presence of plaque (8 studies) was independently associated with future stroke (pooled HR, 1.89 [1.04-3.44]) and cardiac events (7 studies), with a pooled HR, 1.77 (1.19-2.62). Increased coronary artery calcium (5 studies) was associated with the risk of coronary heart disease events, pooled HR, 1.54 (1.07-2.07) and increasing severity of calcification (by Agaston score) was associated with escalation of risk (13 studies). An ankle/brachial index (ABI) of <0.9, the pooled HR for cardiovascular death from 7 studies was 2.01 (1.43-2.81). There were insufficient studies of either, thoracic or aortic calcium, aortic diameter, or femoral plaque to synthesize the data based on consistent reporting of these measures. CONCLUSIONS: The presence of carotid plaque, coronary artery calcium, or abnormal ankle pressure
Golledge J, Thanigaimani S, Powell JT, et al., 2023, Pathogenesis and management of abdominal aortic aneurysm, EUROPEAN HEART JOURNAL, Vol: 44, Pages: 2682-2697, ISSN: 0195-668X
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Machin M, Van Herzeele I, Ubbink D, et al., 2023, Shared Decision Making and the Management of Intact Abdominal Aortic Aneurysm: A Scoping Review of the Literature, EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 65, Pages: 839-849, ISSN: 1078-5884
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- Citations: 2
Pouncey AL, Martin G, Bicknell C, et al., 2023, Why Do Women Stay Longer in Hospital After Elective Endovascular Repair for Infrarenal Aortic Abdominal Aortic Aneurysms? A Nationwide Investigation from the United Kingdom, 49th Annual Symposium on Vascular and Endovascular Issues, Publisher: MOSBY-ELSEVIER, Pages: 28S-28S, ISSN: 0741-5214
Pouncey AL, Sweeting MJ, Bicknell C, et al., 2023, Sex-specific differences in the standard of care for infrarenal abdominal aortic aneurysm repair, and risk of major adverse cardiovascular events and death, BRITISH JOURNAL OF SURGERY, Vol: 110, Pages: 481-488, ISSN: 0007-1323
Boyle JR, Tsilimparis N, Van Herzeele I, et al., 2023, Editor's Choice - Focused Update on Patients Treated with the Nellix EndoVascular Aneurysm Sealing (EVAS) System from the European Society for Vascular Surgery (ESVS) Abdominal Aortic Aneurysm Clinical Practice Guidelines., Eur J Vasc Endovasc Surg, Vol: 65, Pages: 320-322
OBJECTIVE: After alerts on EndoVascular Aneurysm Seal (EVAS) failure were raised, the European Society for Vascular Surgery (ESVS) Abdominal Aortic Aneurysm (AAA) Clinical Practice Guidelines Writing Committee (WC) initiated a task force with the aim to provide guidance on surveillance and management of patients with implanted EVAS devices. METHODS: Based on a scoping review of risk for late serious aortic-related adverse events in patients treated with EVAS for AAA, the ESVS AAA Guidelines WC agreed on recommendations graded according to the European Society of Cardiology (ESC) grading system. RESULTS: EVAS has a very high incidence of late endograft migration resulting in proximal type 1 endoleak with risk of rupture, requiring open conversion with device explantation. The reported mortality rate for elective explantation varies between 0% and 14%, while acute conversion for rupture has a very dismal prognosis with a 67 - 75% mortality rate. CONCLUSION: It is recommended that all patients in whom a Nellix device has been implanted should be identified, properly informed, and enrolled in enhanced surveillance. If device failure is detected, early elective device explantation should be considered in surgically fit patients.
Parker LP, Powell JT, Norman PE, et al., 2023, What's going on in the left common iliac artery?, JOURNAL OF VASCULAR SURGERY, Vol: 77, Pages: 314-315, ISSN: 0741-5214
Machin M, Powell JT, 2023, Developing Core Outcome Sets for Vascular Conditions Across Europe, Not as Easy as It Sounds, EJVES VASCULAR FORUM, Vol: 58, Pages: 1-4, ISSN: 2666-688X
Pouncey AL, Khan A, Alharahsheh B, et al., 2022, Hypothesis for the increased rate of thromboembolic and microembolic complications following abdominal aortic aneurysm repair in women, European Journal of Vascular and Endovascular Surgery, Vol: 63, Pages: 348-349, ISSN: 1078-5884
Powell J, Wanhainen A, 2022, Response to "Re 'One Step Forward, Two Steps Backward'"., Eur J Vasc Endovasc Surg, Vol: 63
Powell JT, Koelemay MJW, 2022, Systematic Reviews of the Literature Are Not Always Either Useful Or the Best Way To Add To Science, EJVES Vascular Forum, Vol: 54, Pages: 2-6, ISSN: 2666-688X
Systematic reviews are becoming more popular as a way of doing research; however, not all systematic reviews are clinically useful and sometimes another type of review (scoping, topical, or critical) would be of greater value to the clinical and scientific community. The different types of review and their use are described, illustrated by examples relevant to vascular surgery.
Powell J, 2021, Low shear stress at baseline predicts expansion and aneurysm-related events in patients with abdominal aortic aneurysm, Circulation: Cardiovascular Imaging, Vol: 14, Pages: 1-12, ISSN: 1941-9651
BackgroundLow shear stress has been implicated in abdominal aortic aneurysm (AAA) expansion and clinical events. We tested the hypothesis that low shear stress in AAA at baseline is a marker of expansion rate and future aneurysm-related events. Methods Patients were imaged with computed tomography angiography (CTA) at baseline and followed up every six months >24 months with ultrasound measurements of maximum diameter. From baseline CTA, we reconstructed three dimensional models for automated computational fluid dynamics simulations and computed luminal shear stress. The primary composite endpoint was aneurysm repair and/or rupture, and the secondary endpoint was aneurysm expansion rate. Results We included 295 patients with median AAA diameter of 49mm (IQR 43-54mm) and median follow-up of 914 (IQR 670-1112) days. There were 114 (39%) aneurysm-related events, with 13 AAA ruptures and 98 repairs (one rupture was repaired). Patients with low shear stress (<0.4 Pa) experienced a higher number of aneurysm-related events (44%) compared to medium (0.4-0.6 Pa; 27%) and high (>0.6 Pa; 29%) shear stress groups (p=0.010). This association was independent of known risk factors (adjusted HR 1.72; 95% CI [1.08, 2.73]; p=0.023). Low shear stress was also independently associated with AAA expansion rate (β=+0.28mm/y; 95% CI [0.02, 0.53]; p=0.037). Conclusions We show for the first time that low shear stress (<0.4 Pa) at baseline is associated with both AAA expansion and future aneurysm-related events. Aneurysms within the lowest tertile of shear stress, versus those with higher shear stress, were more likely to rupture or reach thresholds for elective repair. Larger prospective validation trials are needed to confirm these findings and translate them into clinical management.
Bappoo N, Syed MBJ, Khinsoe G, et al., 2021, Low Shear Stress at Baseline Predicts Expansion and Aneurysm-Related Events in Patients With Abdominal Aortic Aneurysm., Circ Cardiovasc Imaging, Vol: 14, Pages: 1112-1121
BACKGROUND: Low shear stress has been implicated in abdominal aortic aneurysm (AAA) expansion and clinical events. We tested the hypothesis that low shear stress in AAA at baseline is a marker of expansion rate and future aneurysm-related events. METHODS: Patients were imaged with computed tomography angiography at baseline and followed up every 6 months >24 months with ultrasound measurements of maximum diameter. From baseline computed tomography angiography, we reconstructed 3-dimensional models for automated computational fluid dynamics simulations and computed luminal shear stress. The primary composite end point was aneurysm repair and/or rupture, and the secondary end point was aneurysm expansion rate. RESULTS: We included 295 patients with median AAA diameter of 49 mm (interquartile range, 43-54 mm) and median follow-up of 914 (interquartile range, 670-1112) days. There were 114 (39%) aneurysm-related events, with 13 AAA ruptures and 98 repairs (one rupture was repaired). Patients with low shear stress (<0.4 Pa) experienced a higher number of aneurysm-related events (44%) compared with medium (0.4-0.6 Pa; 27%) and high (>0.6 Pa; 29%) shear stress groups (P=0.010). This association was independent of known risk factors (adjusted hazard ratio, 1.72 [95% CI, 1.08-2.73]; P=0.023). Low shear stress was also independently associated with AAA expansion rate (β=+0.28 mm/y [95% CI, 0.02-0.53]; P=0.037). CONCLUSIONS: We show for the first time that low shear stress (<0.4 Pa) at baseline is associated with both AAA expansion and future aneurysm-related events. Aneurysms within the lowest tertile of shear stress, versus those with higher shear stress, were more likely to rupture or reach thresholds for elective repair. Larger prospective validation trials are needed to confirm these findings and translate them into clinical management.
Powell JT, 2021, Great vascular surgeons needed for great aneurysms, Journal of Vascular Surgery, Vol: 74, Pages: 1161-1162, ISSN: 0741-5214
Powell JT, Wanhainen A, 2021, One Step Forward, Two Steps Backward? COMMENT, EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 62, Pages: 642-642, ISSN: 1078-5884
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Powell JT, 2021, Re: "Systemic Review and Meta-Analysis of the Effect of Weekend Admission on Outcomes for Ruptured Abdominal Aortic Aneurysms", EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 62, Pages: 660-660, ISSN: 1078-5884
Pouncey AL, David M, Morris R, et al., 2021, Systematic review and meta-analysis of sex-specific differences in adverse events after open and endovascular intact abdominal aortic aneurysm repair: consistent worse outcomes for women, European Journal of Vascular and Endovascular Surgery, Vol: 62, Pages: 367-378, ISSN: 1078-5884
Objective: Previously, reports have shown women experience higher mortality than men after elective open (OAR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA).With recent improvements in overall AAA repair outcomes, this study aimed to identify whether sex-specific disparity has been ameliorated by modern practice, and to define sex-specific differences in peri/post-operative complications and pre-operative status; factors which may contribute to poor outcome.Methods: Systematic review, meta-analysis and meta-regression of sex-specific differences in 30-day mortality and complications conducted according to PRISMA guidance (Prospero registrationCRD42020176398). Papers with ≥50 women, reporting sex-specific outcomes, following intact primary AAA repair, from 2000-2020 world-wide were included; separate analyses for EVAR and OAR. Data sources: Medline, Embase and CENTRAL databases 2005-2020 searched using ProQuest Dialog™. Results: 26 studies (371,215 men,65,465 women) included. Meta-analysis and meta-regression indicated sex-specific odds ratios(ORs) for 30-day mortality were unchanged from 2000-2020.Mortality risk was higher in women for OAR and more so for EVAR (OR [95%CI] 1.49 [1.37,1.61];1.86 [1.59,2.17] respectively) and remained following multivariable risk-adjustment. Transfusion, pulmonary complications and bowel ischemia were more common in women after OAR and EVAR (OAR: ORs 1.81 [1.60,2.04], 1.40 [1.28,1.53], 1.54 [1.36,1.75]; EVAR: ORs 2.18[2.08,2.29] 1.44 [1.17,1.77], 1.99 [1.51,2.62] respectively). Arterial injury, limb ischemia, renal and cardiac complications were more common in women after EVAR (ORs 3.02 [1.62-5.65], 2.13[1.48-3.06], 1.46 [1.22-1.72] and 1.19[1.03,1.37] respectively); the latter was associated with greater mortality risk on meta-regression. Conclusions: Increased mortality risk for women following AAA repair remains. Women had higher incidence of transfusion, pulmonary and bowel complications after EVAR and
Pouncey AL, Alharehsheh B, Khan A, et al., 2021, Quantification of Sex-specific Differences in Aorto-iliac Complexity for Patients Undergoing Abdominal Aortic Aneurysm Repair: A Retrospective Cohort Study., Vascular Society Annual Scientific Meeting 2021
Pouncey A-L, Powell JT, 2021, Womens lives at stake: Women Suffer Disproportionately After Abdominal Aortic Aneurysm Repair, So What Can We Do About It?, EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 62, Pages: 1-3, ISSN: 1078-5884
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Machin M, Ulug P, Pandirajan K, et al., 2021, Towards a core outcome set for abdominal aortic aneurysm: systematic review of outcomes reported following intact and ruptured abdominal aortic aneurysm repair, European Journal of Vascular and Endovascular Surgery, Vol: 61, Pages: 909-918, ISSN: 1078-5884
Objective:To encompass the needs of all stakeholders and allow effective data synthesis from trials, registries, and other studies; a core outcome set for infrarenal abdominal aortic aneurysm (AAA) repair is needed. In this first stage, the aim was to report the range, frequency, and time of pre-specified outcomes reported following AAA repair.Data Sources:Medline, Embase, and CENTRAL databases 2010 – 2019 were searched using ProQuest Dialog™.Review Methods:The systematic review was reported to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA), PROSPERO registration CRD42019130119. Outcomes were coded using Core Outcome Measures in Effectiveness Trials (COMET) taxonomy and presented separately for intact and rupture repairs, endovascular aneurysm repair (EVAR) and open repair, and time from repair (acute < 90 days vs. ≥ 1 year) (COMET Initiative 1582).Results:For intact AAA and rupture repair, a total of 231 and 70 reports with 589 255 and 177 465 patients respectively were included: only 98 and 19 respectively provided ≥ 1 year outcomes. Most studies were retrospective, with 13 randomised trials of intact AAA repair and five randomised trials of ruptured AAA repair. For intact AAA, the most common pre-specified COMET taxonomy outcomes were mortality (181), vascular complications (137), and re-intervention (52). EVAR studies dominated the vascular outcomes in acute and later time periods: excluding 47 reports from device registries, reduced vascular outcomes to 83. For ruptured AAA, the three most common outcomes were mortality (64), vascular (11), and hospital stay (10). The range of outcomes reported was wide with functioning outcomes reported from most randomised trials but few retrospective studies.Conclusion:This review identifies the paucity of long term data and the disproportionate attention paid to vascular complications vs. patient functioning outcomes, this skew being accentuated by reporting from
Pouncey AL, David M, Morris R, et al., 2021, THE IMPACT OF CARDIOVASCULAR DISEASE ON SEX-SPECIFIC ADVERSE OUTCOMES FOLLOWING INTACT ABDOMINAL AORTIC ANEURYSM REPAIR: A SYSTEMATIC REVIEW, META-ANALYSIS & META-REGRESSION, Publisher: BMJ PUBLISHING GROUP, Pages: A30-A32, ISSN: 1355-6037
Ulug P, Powell JT, 2020, Clinical trial reporting, LANCET, Vol: 396, Pages: 1489-1489, ISSN: 0140-6736
Powell JT, 2020, Lost in Translation From Mice to Men: Grief and Pain and FAME, EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY, Vol: 60, Pages: 461-461, ISSN: 1078-5884
Doyle BJ, Bappoo N, Syed MBJ, et al., 2020, Biomechanical assessment predicts aneurysm related events in patients with abdominal aortic aneurysm, European Journal of Vascular and Endovascular Surgery, Vol: 60, Pages: 365-373, ISSN: 1078-5884
ObjectiveTo test whether aneurysm biomechanical ratio (ABR; a dimensionless ratio of wall stress and wall strength) can predict aneurysm related events.MethodsIn a prospective multicentre clinical study of 295 patients with an abdominal aortic aneurysm (AAA; diameter ≥ 40 mm), three dimensional reconstruction and computational biomechanical analyses were used to compute ABR at baseline. Participants were followed for at least two years and the primary end point was the composite of aneurysm rupture or repair.ResultsThe majority were male (87%), current or former smokers (86%), most (72%) had hypertension (mean ± standard deviation [SD] systolic blood pressure 140 ± 22 mmHg), and mean ± SD baseline diameter was 49.0 ± 6.9 mm. Mean ± SD ABR was 0.49 ± 0.27. Participants were followed up for a mean ± SD of 848 ± 379 days and rupture (n = 13) or repair (n = 102) occurred in 115 (39%) cases. The number of repairs increased across tertiles of ABR: low (n = 24), medium (n = 34), and high ABR (n = 44) (p = .010). Rupture or repair occurred more frequently in those with higher ABR (log rank p = .009) and ABR was independently predictive of this outcome after adjusting for diameter and other clinical risk factors, including sex and smoking (hazard ratio 1.41; 95% confidence interval 1.09–1.83 [p = .010]).ConclusionIt has been shown that biomechanical ABR is a strong independent predictor of AAA rupture or repair in a model incorporating known risk factors, including diameter. Determining ABR at baseline could help guide the management of patients with AAA.
Ulug P, Powell JT, Martinez MA-M, et al., 2020, Surgery for small asymptomatic abdominal aortic aneurysms., Cochrane Database of Systematic Reviews, Vol: 7, Pages: CD001835-CD001835, ISSN: 1469-493X
BACKGROUND: An abdominal aortic aneurysm (AAA) is an abnormal ballooning of the major abdominal artery. Some AAAs present as emergencies and require surgery; others remain asymptomatic. Treatment of asymptomatic AAAs depends on many factors, but the size of the aneurysm is important, as risk of rupture increases with aneurysm size. Large asymptomatic AAAs (greater than 5.5 cm in diameter) are usually repaired surgically; very small AAAs (less than 4.0 cm diameter) are monitored with ultrasonography. Debate continues over the roles of early repair versus surveillance with repair on subsequent enlargement in people with asymptomatic AAAs of 4.0 cm to 5.5 cm diameter. This is the fourth update of the review first published in 1999. OBJECTIVES: To compare mortality and costs, as well as quality of life and aneurysm rupture as secondary outcomes, following early surgical repair versus routine ultrasound surveillance in people with asymptomatic AAAs between 4.0 cm and 5.5 cm in diameter. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, two other databases, and two trials registers to 10 July 2019. We handsearched conference proceedings and checked reference lists of relevant studies. SELECTION CRITERIA: We included randomised controlled trials where people with asymptomatic AAAs of 4.0 cm to 5.5 cm were randomly allocated to early repair or imaging-based surveillance at least every six months. Outcomes had to include mortality or survival. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data, which were cross-checked by other team members. Outcomes were mortality, costs, quality of life, and aneurysm rupture. For mortality, we estimated risk ratios (RR) (endovascular aneurysm repair only), hazard ratios (HR) (open repair only), and 95% confidence intervals (CI) based on Mantel-Haenszel Chi2 statistics at one and six years (open repair only) following randomisation
Powell JT, Wanhainen A, 2020, Analysis of the differences between the European Society for Vascular Surgery 2019 and National Institute for Health and Care Excellence 2020 guidelines for abdominal aortic aneurysm, European Journal of Vascular and Endovascular Surgery, Vol: 60, Pages: 7-15, ISSN: 1078-5884
ObjectiveThe aim was to understand why two recently published guidelines for the diagnosis and management of patients with abdominal aortic aneurysm, the National Institute for Health and Care Excellence (NICE) 2020 guidelines and the European Society for Vascular Surgery (ESVS) 2019 guidelines, have discordant recommendations in several important areas.MethodsA review of the approach, methodology, and evidence used by the two guideline committees was carried out to understand potential reasons for their differing recommendations in their two final published guidelines.ResultsNICE guidelines use a multidisciplinary committee to address a limited number of prospectively identified questions, using rigorous methods heavily reliant on evidence from randomised controlled trials (RCTs) supported by in house economic modelling, with the purpose of providing the best, cost-effective health care in the UK in 46 main recommendations. The ESVS guidelines use an expert committee to encourage clinical effectiveness across a range of European health economies. ESVS guideline topics, but not questions, are prospectively identified, assessment of evidence was less rigorous, and 125 recommendations were made. More up to date evidence searches by the ESVS committee partially underscore the differences in recommendations for screening women. The NICE committee did not consider sex specific analysis or evidence for thresholds for intervention but relied on sex specific modelling to support their advice to use endovascular repair (EVAR) for ruptures in women. Their recommendation to use open repair for ruptured abdominal aortic aneurysms (AAAs) in men aged < 71 years was based on in house economic modelling. NICE recommends an open first strategy for non-ruptured AAA mainly based on earlier RCTs and UK specific economic modelling, while the ESVS guidelines recommend an EVAR first strategy after consideration of modern, but lower quality, evidence from observational studies. Similar
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