Understanding the New ESVS Recommendation Grading System
The European Society for Vascular Surgery (ESVS) has introduced a revised grading system in its Clinical Practice Guidelines, aiming to enhance clarity and consistency in clinical decision-making. This updated framework is designed to better reflect the strength of recommendations and the quality of supporting evidence.
The Evolution of the ESVS Clinical Practice Guidelines Grading System
The grading system used in the European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines has undergone a thoughtful update, building upon a system that was originally adapted from the European Society of Cardiology over 20 years ago. This earlier system predates the professionalization of guideline development, which now involves detailed frameworks such as AGREE II checklists and evidence appraisal tools like GRADE.
Recognizing the need for a more robust system, the ESVS Guidelines Steering Committee acknowledged that while the previous grading structure was functional, it required refinement to meet the modern standards of evidence-based medicine. However, they also understood the importance of maintaining continuity for clinicians familiar with the existing framework. Therefore, rather than abandoning the original system, the committee decided to update it while preserving its core structure.
This updated system, which will now be referred to as the European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines Class of Recommendation Grading System, aims to ensure that recommendations remain both clinically relevant and easy to apply in everyday practice. The goal is to provide clear, actionable guidelines that enhance patient care without overcomplicating the decision-making process. This evolution reflects the growing need to integrate high-quality evidence with practical, patient-centered recommendations.
Updated recommendations in the new grading system
The grading system categorizes recommendations into three classes:
Class I: Procedures or treatments that are beneficial, useful, and effective.(is or are recommended)
- Class II: Conflicting evidence. Divided into:
- IIa: Evidence favors usefulness or efficacy.(should be considered)
- IIb: Usefulness or efficacy is less well established.(may be considered)
- Class III: Procedures or treatments that are not recommended, as they are not useful or may be harmful.
- IIIa: Not necessarily useful or effective.(is or are not indicated)
- IIIb: May be dangerous or harmful to patients.(is or are not recommended)
A Closer Look at Class III: Refining the Language of Recommendations
One of the most notable updates in the newly revised ESVS grading system is the refinement of Class III recommendations. Traditionally, Class III was used broadly to indicate that a treatment or procedure was not useful, effective, or potentially harmful. However, the updated guidelines now acknowledge that not all negative recommendations carry the same weight or clinical implications.
To reflect this nuance, Class III has been subdivided into Class IIIA and Class IIIB. This change is based on the recognition that some interventions may simply lack proven benefit without necessarily causing harm—these now fall under Class IIIA. In contrast, Class IIIB is reserved for treatments or procedures that may pose actual risks to patients and are therefore explicitly discouraged.
This differentiation adds important clarity. By distinguishing between “not useful” and “potentially harmful,” the updated classification helps clinicians make more informed, patient-centered decisions. It’s a subtle but significant step toward more precise, evidence-based practice.
As the field of vascular surgery continues to evolve, these refinements in guideline language ensure that recommendations remain both scientifically rigorous and clinically practical. Ultimately, they serve the shared goal of enhancing the quality and safety of patient care.
Updated level of evidence grading
Each recommendation is also assigned a level of evidence:
Level A: Data derived from multiple randomised trials or meta-analyses of randomised trials
Level B: Data derived from a single randomised trial, high quality∗ non-randomised studies, or a meta-analysis of such studies
Level C: Consensus opinion of experts, data from low quality∗∗ studies, or meta-analysis of such studies
∗Large, prospective, population based, observational or registry studies.
∗∗Small, retrospective studies or case series.
This structured approach aids clinicians in evaluating the reliability of recommendations, ensuring that patient care decisions are informed by the best available evidence. By standardizing the grading system, the ESVS aims to facilitate clearer communication among healthcare professionals and improve patient outcomes.
For a comprehensive understanding, refer to the full guidelines published in the European Journal of Vascular and Endovascular Surgery.