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July 21, 2020

Differences Between ESVS 2019 and NICE 2020 AAA Guidelines Analyzed

July 21, 2020—An analysis of the differences between the European Society for Vascular Surgery (ESVS) 2019 guidelines for abdominal aortic aneurysm (AAA) and the UK National Institute for Health and Care Excellence 2020 AAA guidelines was published by Janet T. Powell, MD, and Anders Wanhainen, MD, in the European Journal of Vascular & Endovascular Surgery (EJVES; 2020;60:7–15).

Dr. Powell and Dr. Wanhainen conducted a review of the approach, methodology, and evidence used by the two committees to understand why the sets of guidelines for the diagnosis and management of patients with AAA have discordant recommendations in several important areas.

Dr. Powell is from the Vascular Surgery Research Group at Imperial College London in London, United Kingdom. Dr. Wanhainen is Professor of Vascular Surgery, Department of Surgical Sciences, at Uppsala University in Uppsala, Sweden.

As summarized in the EJVES abstract, the investigators reported the following:

  • NICE guidelines used a multidisciplinary committee to address a limited number of prospectively identified questions.
  • NICE guidelines used rigorous methods heavily reliant on evidence from randomized controlled trials (RCTs) supported by in-house economic modelling, with the purpose of providing the best cost-effective health care in the United Kingdom in 46 main recommendations.
  • ESVS guidelines used an expert committee to encourage clinical effectiveness across a range of European health economies.
  • ESVS guideline topics, but not questions, were prospectively identified, assessment of evidence was less rigorous, and 125 recommendations were made.

Regarding specific recommendations, Dr. Powell and Dr. Wanhainen found:

  • The ESVS committee's more up-to-date evidence searches partially underscored 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 the advice to use endovascular repair (EVAR) for ruptured AAA in women.
  • NICE guidelines' recommendation to use open repair for ruptured AAAs in men age < 71 years was based on in-house economic modelling.
  • NICE guidelines' recommendation to use an open-first strategy for nonruptured AAA is mainly based on earlier RCTs and United Kingdom-specific economic modelling.
  • ESVS guidelines' recommendation for an EVAR-first strategy is based on modern, but lower-quality evidence from observational studies.
  • Similar reasons explain differences in the recommended treatments of juxtarenal aneurysms.

The analysis concluded that differences between the NICE and ESVS guidelines can be explained, at least in part, by their differing perspectives, methodologies, and quality assurance. Future ESVS guidelines may benefit from more multidisciplinary input and prospectively identified questions, advised Dr. Powell and Dr. Wanhainen in EJVES.

In the March 2020 issue of Endovascular Today, Dr. Wanhainen published "Highlights and Key Updates to the ESVS AAA Guidelines," which reviewed important revisions to the guidelines and their impact on practice (2020;19:60–66).

Also in the March issue of Endovascular Today, "NICE AAA Guidance: Where We Are Now and How We Got Here," by Michael Jenkins, BSc, MBBS, provided an overview of the criticism, support, and validity of the draft NICE guidelines for managing AAA, plus a first look at the finalized guidance.

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