ESVS AAA guidelines compared to German national guidelines—Can the discrepancies be resolved?

Abstract Background Abdominal aortic aneurysm (AAA) guidelines provide critical frameworks for screening, diagnosis, treatment and surveillance. Differences between national and European guidelines may affect clinical practice and patient outcomes. Objective To compare the 2024 European Society for Vascular Surgery (ESVS) AAA guidelines with the 2018 German S3 guidelines, focusing on key differences in four domains: minimum procedural volume, screening, threshold for repair and guideline scope. Material and methods A comparison of both guideline recommendations was conducted, focusing on key controversial areas to allow an in-depth analysis of their differences. Results The 2024 ESVS guidelines reinforce institutional minimum volume thresholds, recommending ≥30 annual AAA repairs, including ≥15 each by open and endovascular means and ≥20 complex cases, while there are no volume requirements specified in the German S3 guidelines. Screening recommendations in the ESVS update now target high-risk populations, while German recommendations retain fixed age-based and sex-based criteria. Both guidelines recommend repair at ≥ 55 mm in men and ≥50 mm in women but the ESVS emphasizes restraint in early intervention and recommends confirming rapid growth before repair. It also defers computed tomography angiography (CTA) until repair thresholds are met. The German guidelines are more permissive in early repair and growth-driven decisions. Conclusion While both the ESVS 2024 and 2018 German S3 guidelines are grounded in a largely overlapping evidence base, their recommendations differ substantially in specific areas. Some of these differences may be explained by the timing of publication, as the ESVS guidelines were released 6 years later, and by ongoing evidence gaps, while others reflect broader contrasts in healthcare systems, priorities and implementation frameworks. Appreciating these variations supports mutual understanding and contributes to ongoing efforts toward improving vascular care across Europe.