NICE has published an updated guideline on the diagnosis and management of abdominal aortic aneurysms (AAA).
The final guideline follows an extended period of review after the 2018 draft guideline recommended that endovascular aneurysm repair (EVAR) should not be used in the repair of unruptured aneurysms.
Critics said the lack of flexibility would potentially limit clinical judgement and patient choice in selecting the most appropriate intervention for some people.
Stakeholders also argued that it would not be possible to rapidly implement recommendations that favoured open surgical repair (OSR) over EVAR where current practice overwhelmingly favours EVAR over OSR.
NICE has made a number of changes. The guideline now recommends people be offered OSR of unruptured AAAs. Where OSR is contraindicated, EVAR, and in some cases conservative management, can be considered.
Paul Chrisp, director of the Centre for Guidelines at NICE, said: “We are confident that the majority of the stakeholder community will give a positive response to the guideline, now that the recommendations do not unequivocally rule out EVAR.
“We know that some clinicians prefer EVAR but what we are trying to do is steer the system to shift practice towards open surgery, in line with the evidence.
“There is a recognition that EVAR may have been used in some patients when open surgery would have been suitable, but that ‘do not offer’ EVAR is too inflexible to reflect the fact that assessment of individual patients by multidisciplinary teams for the most suitable management option, and involving them in treatment decisions, is how the system works,” Mr Chrisp said.
He said: “The revised wording reflects more fully the complex implementation issues associated with shifting a dominant practice in line with what the evidence indicates, gaining the support of the system and patients to start putting the recommendations into practice, and the need for practice to move towards open repair.”
The guideline recommendations include:
- Encouraging all men aged ≥65 years to take part in the NHS AAA screening programme.
- Women ≥70 years being investigated for possible AAA should be considered for an ultrasound scan if they have any risk factors, including hypercholesterolaemia, hypertension, or current/former smoking practice.
- Patients with ultrasound-confirmed abdominal aorta diameter ≥5.5cm should be seen by the regional vascular service within two weeks.
- People with an aorta diameter of between 3.5 and 5.4 cm should be seen within 12 weeks.