Rethinking Thresholds for AAA Repair in Men: A Call for Evidence-Based Change

In an editorial titled “Third Time’s the Charm: It’s Time to Raise the Threshold for Elective Abdominal Aortic Aneurysm Repair in Men!” published in the European Journal of Vascular and Endovascular Surgery (2025), Wanhainen and Stone revisit the long-standing 5.5 cm intervention threshold for abdominal aortic aneurysms (AAAs) in men. Despite four landmark RCTs—UKSAT, ADAM, CAESAR, and PIVOTAL—supporting surveillance for AAAs under this threshold, the rationale for maintaining it has come under renewed scrutiny.

The authors argue compellingly for an increased threshold of 6.0 cm, drawing on historical data from the Chichester and MASS screening trials and more recent findings from the UK’s NAAASP. Crucially, the annual rupture risk for AAAs measuring 5.0–5.5 cm (inner-to-inner via ultrasound) is just 0.4%, equivalent to 6.0 cm when measured via CT. This suggests that the widely endorsed 5.5 cm benchmark may be overly conservative.

They further address misconceptions around ruptures <5.5 cm, emphasizing the skewed distribution of AAA sizes and the disproportionately low rupture risk among smaller aneurysms. Moreover, a U.S.-based Markov model also supports a >6 cm threshold to optimize mortality outcomes.

While the ESVS 2024 guidelines maintain the 5.5 cm recommendation, the editorial supports a more individualized, risk-stratified approach, invoking the principle of primum non nocere. The authors caution against overtreatment and emphasize the importance of aligning surgical intervention with robust, contemporary evidence—particularly in a procedure with inherent risks and uncertain benefit for smaller aneurysms.