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The concept of risk assessment and the identification of surgical unfitness for vascular intervention is a particularly controversial issue today as the minimally invasive surgical population has increased not only in volume but also in complexity (comorbidity profile) and age, requiring an improved pre-operative selection and definition of high risk. A practical step by step (three steps, two points for each) approach for surgical risk assessment is suggested in this review. As a general rule, the identification of a "high risk" patient for vascular surgery follows a step by step process where the risk is clearly defined, quantified (when too "high"?), and thereby stratified based on the procedure, the patient, and the hospital, with the aid of predictive risk scores. However, there is no standardized, updated, and objective definition for surgical unfitness today. The major gap in the current literature on the definition of high risk in vascular patients explains the lack of sound validated predictive systems and limited generalizability of risk scores in vascular surgery. In addition, the concept of fitness is an evolving tool and many traditional high risk criteria and definitions are no longer valid. Given the preventive purpose of most vascular procedures performed in elderly asymptomatic patients, the decision to pursue or withhold surgery requires realistic estimates not only regarding individual peri-operative mortality, but also life expectancy, healthcare priorities, and the patient's primary goals, such as prolongation of life versus maintenance of independence or symptom relief. The overall "frailty" and geriatric risk burden, such as cognitive, functional, social, and nutritional status, are variables that should be also included in the analyses for stratification of surgical risk in elderly vascular patients.

Epidemiologic evidence suggests that patients with diabetes may have a lower incidence of abdominal aortic aneurysm (AAA); however, the link between diabetes and AAA development and expansion is unclear. The aim of this review is to analyze updated evidence to better understand the impact of diabetes on prevalence, incidence, clinical outcome, and expansion rate of AAA. A systematic review of literature published in the last 20 years using the PubMed and Cochrane databases was undertaken. Studies reporting appropriate data were identified and a meta-analysis performed using the generic inverse variance method. Sixty-four studies were identified. Methodological quality was “fair” in 16 and “good” in 44 studies according to a formal assessment checklist (Newcastle–Ottawa). In 17 large population prevalence studies there was a significant inverse association between diabetes and AAA: pooled odds ratio (OR) 0.80; 95% confidence intervals (CI) 0.70–0.90 (p = .0009). An inverse association was also confirmed by pooled analysis of data from smaller prevalence studies on selected populations (OR 0.59; 95% CI 0.35–0.99; p = .05), while no significant results were provided by case-control studies. A significant lower pooled incidence of new AAA in diabetics was found over six prospective studies: OR 0.54; 95% CI 0.31–0.91; p = .03. Diabetic patients showed increased operative (30-day/in-hospital) mortality after AAA repair: pooled OR 1.26; 95% CI 1.10–1.44; p = .0008. The increased operative risk was more evident in studies with 30-day assessment. In the long-term, diabetics showed lower survival rates at 2–5 years, while there was general evidence of lower growth rates of small AAA in patients with diabetes compared to non-diabetics. There is currently evidence to support an inverse relationship between diabetes and AAA development and enlargement, even though fair methodological quality or unclear risk of bias in many available studies decreases the strength of the finding. At the same time, operative and long-term survival is lower in diabetic patients, suggesting increased cardiovascular burden. The higher mortality in diabetics raises the question as to whether AAA repair should be individualized in selected diabetic populations at higher AAA rupture risk.

ObjectiveCurrent data supporting the effect of anticoagulation drug use on aneurysm sealing and the durability of endovascular abdominal aneurysm repair (EVAR) are conflicting. This study assessed the safety of chronic anticoagulation therapy after EVAR.MethodsRecords of 1409 consecutive patients having elective EVAR during 1997–2011 who were prospectively followed were reviewed. Survival, reintervention, conversion, and endoleak rates were analyzed in patients with and without chronic anticoagulants. Cox proportional hazards models were used to estimate the effect of anticoagulation therapy on outcomes.ResultsOne-hundred and three (7.3%) patients were on chronic anticoagulation drugs (80 on vitamin K antagonists) at the time of EVAR. An additional 46 patients started on anticoagulants after repair were identified. Patients on chronic anticoagulation therapy at repair (mean age 73.6 years; 91 males) had more frequent cardiac disease (74.8% vs. 44.2%; p

BackgroundOperator training is a key factor for the safety of carotid stenting (CAS). Whether institutional practice is associated with improved individual operator outcomes is debated.ObjectiveTo evaluate the effect of the institutional experience on outcomes of new trainees with CAS, a retrospective analysis of a prospectively held database was performed.MethodsThe overall study period, 2004–2012, was divided into two sequential time frames: 2004–April 2006 (leaders-team phase) and May 2006–2012 (expanded team phase). In the first frame, a single leader-operators team that first approached CAS and passed the original institutional learning curve, performed all the procedures; in the following expanded-team phase, five new trainees joined. Institutional CAS training for new trainees was based on a team-working approach including selection of patients, devices and techniques and collegial meetings with critical review and discussion of all procedural steps and imaging.ResultsA total of 431 CAS procedures were performed in the leaders-team phase and 1026 in the sequential expanded-team phase. Periprocedural complication rates in the two time frames were similar: stroke/death (3.0% vs. 2.1%; P = 0.35), stroke (2.8% vs. 2.1%; P = 0.45) major stroke (0.9% vs. 0.6%, P = 0.49), death (0.2% vs. 0%; P = 0.29) during the leaders-team and expanded-team phase, respectively. However, rates of CAS failure requiring surgical conversions (3.7% vs. 0.8%; P

Background Iliac branch device (IBD) technique has been introduced as an appealing and effective solution to avoid complications occurring during repair of aorto-iliac aneurysm with extensive iliac involvement. Nevertheless, no large series with long-term follow-up of IBD are available. The aim of this study was to analyse safety and long-term efficacy of IBD in a consecutive series of patients. Methods Between 2006 and 2011, 100 consecutive patients were enrolled in a prospective database on IBD. Indications included unilateral or bilateral common iliac artery aneurysms combined or not with abdominal aneurysms. Patients were routinely followed up with computed tomography. Data were reported according to the Kaplan–Meier method. Results There were 96 males, mean age 74.1 years. Preoperative median common iliac aneurysm diameter was 40 mm (interquartile range (IQR): 35–44 mm). Sixty-seven patients had abdominal aortic aneurysm >35 mm (IQR: 40–57 mm) associated with iliac aneurysm. Eleven patients presented hypogastric aneurysm. Twelve patients underwent isolated iliac repair with IBD and 88 patients received associated endovascular aortic repair. Periprocedural technical success rate was 95%, with no mortality. Two patients experienced external iliac occlusion in the first month. At a median follow-up of 21 months (range 1–60) aneurysm growth >3 mm was detected in four iliac (4%) arteries. Iliac endoleak (one type III and two distal type I) developed in three patients and buttock claudication in four patients. Estimated patency rate of internal iliac branch was 91.4% at 1 and 5 years. Freedom from any reintervention rate was 90% at 1 year and 81.4% at 5 years. No late ruptures occurred. Conclusions Long-term results show that IBD use can ensure persistent iliac aneurysm exclusion at 5 years, with low risk of reintervention. This technique can be considered as a first endovascular option in patients with extensive iliac aneurysm disease and favourable anatomy.

Structured follow-up after revascularisation for chronic critical limb ischaemia (CLI) aims at sustained treatment success and continued best patient care. Thereby, efforts need to address three fundamental domains: (A) best medical therapy, both to protect the arterial reconstruction locally and to reduce atherosclerotic burden systemically; (B) surveillance of the arterial reconstruction; and (C) timely initiation of repeat interventions. As most CLI patients are elderly and frail, sustained resolution of CLI and preserved ambulatory capacity may decide over independent living and overall prognosis. Despite this importance, previous guidelines have largely ignored follow-up after CLI; arguably because of a striking lack of evidence and because of a widespread assumption that, in the context of CLI, efficacy of initial revascularisation will determine prognosis during the short remaining life expectancy. This chapter of the current CLI guidelines aims to challenge this disposition and to recommend evidentially best clinical practice by critically appraising available evidence in all of the above domains, including antiplatelet and antithrombotic therapy, clinical surveillance, use of duplex ultrasound, and indications for and preferred type of repeat interventions for failing and failed reconstructions. However, as corresponding studies are rarely performed among CLI patients specifically, evidence has to be consulted that derives from expanded patient populations. Therefore, most recommendations are based on extrapolations or subgroup analyses, which leads to an almost systematic degradation of their strength. Endovascular reconstruction and surgical bypass are considered separately, as are specific contexts such as diabetes or renal failure; and critical issues are highlighted throughout to inform future studies.

Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed.This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade.

Background Pre-manufactured branched grafts now allow an endovascular approach to the repair of thoraco-abdominal aortic aneurysm (TAAA) with visceral vessels' involvement. Similar grafts have been employed in open surgery, generally as a second choice for TAAAs, which are not amenable to patch/inclusion technique for visceral vessel attachment. Results with branched grafts have not been reported in series of open TAAA repairs. The purpose of this report is to describe perioperative risks and outcomes in a consecutive series of patients with pre-manufactured side-branched thoracoabdominal aortic grafts (STAGs) for surgical TAAA repair. Methods Between 1996 and 2009, pre-manufactured STAGs were used in 50 patients with TAAA that required reattachment of the visceral and renal arteries. Operative details, perioperative mortality and ischaemic complications were examined. Results Mean age was 53 years; 18 patients were females. The cases included redo ( n = 24), patients affected by genetic disorder (Marfan) ( n = 20) and patients with aortic dissection ( n = 27). The mean clamp time was 84.1 min. Perioperative mortality was 12.0% (6/50). Neurologic deficits occurred in 2% (1/50). Postoperative renal dysfunction was detected in 19 patients (38%). Conclusion The use of a STAG produced acceptable mortality, bowel and neurological ischaemic risks. Improved strategies to prevent renal ischaemia before and during repair of TAAA with visceral involvement are needed.

BackgroundRandomised trials have failed to demonstrate benefit from early surgical repair of small abdominal aortic aneurysm (AAA) compared with surveillance. This study aimed to compare results after endovascular aortic aneurysm repair (EVAR) or surveillance in AAA 1 cm /year, symptoms) was achieved. The main end point was all-cause mortality. Recruitment is closed; results at a median follow-up of 32.4 months are here reported.ResultsBetween 2004 and 2008, 360 patients (early EVAR = 182; surveillance = 178) were enrolled. One perioperative death after EVAR and two late ruptures (both in the surveillance group) occurred. At 54 months, there was no significant difference in the main end-point rate [hazard ratio (HR) 0.76; 95% confidence interval (CI) 0.30–1.93; p = 0.6] with Kaplan–Meier estimates of all-cause mortality of 14.5% in the EVAR and 10.1% in the surveillance group. Aneurysm-related mortality, aneurysm rupture and major morbidity rates were similar. Kaplan–Meier estimates of aneurysms growth ≥5 mm at 36 months were 8.4% in the EVAR group and 67.5% in the surveillance group (HR 10.49; 95% CI 6.88–15.96; p

ObjectiveThe clinical significance of Haemodynamic Depression (HD) during carotid stenting (CAS) remains unclear. The aim of this study was to analyze the frequency and predictors of HD during CAS in a single centre experience.MethodsA prospective protocol for CAS was applied in a 15-month interval. Patients with restenosis, on betablockers, or with arrhythmias were excluded. A standardized dose of atropine (0.4mg) was given prior to stent deployment. Changes in heart rate, blood pressure, and neurological status were monitored and recorded. HD was defined as systolic pressure

The decision to palliate, that is to withhold potentially effective treatment, is justified by the belief that the treatment is of no benefit and that it would carry excess mortality risk. Nevertheless, concerns remain over when, why, and whether palliating patients with abdominal aortic aneurysm (AAA)makes sense, as the decision is still largely based on the subjective interpretation of harsh reality. Critical appraisal of sound evidence suggests that there are no reliable or valid criteria to establish whether to treat an aneurysm in either the elective or emergency situation. It has been suggested that there will always be some patients at “highest risk,” “unsuitable for intervention,” in whom the risk of elective large AAA repair will outweigh potential survival benefits. Given that the likelihood of death from non-aneurysm related causes is greater than that from the aneurysm itself, and that life expectancy would not increase despite intervention, palliation should be offered to these patients. However, how the “highest risk”or “unfitness” profile should be objectively and reliably measured, to withhold elective aneurysm repair, remains debatable and not standardized. Even more challenging is the decision to turn down patients with ruptured AAA (rAAA) as suggested in the paper by the Amsterdam Acute Aneurysm Trial group (AIAX trial) published in this issue of European Journal of Vascular and Endovascular Surgery. Authors tested a number of well known, already developed, predictive models, some refined for patients with rAAA, to identify subgroups at high mortality risk, based on a variety of demographics, comorbidity, and severity conditions (e.g. Hardman index, Vancouver scoring system, updated Glasgow Aneurysm Score [GAS], and Edinburgh Ruptured Aneurysm Score). Nevertheless, the study showed only limited and insufficient performance of all the current prognostic models when applied to 449 real patients with rAAA treated in 10 Netherlands hospitals in modern times (after 2004). Onemain finding derived from this validation study was the general tendency to overestimate the true death rates according to predicted values, and also using the updated GAS model shown to be the most reliable and accurate in prediction of death (60% in GAS vs. 54% observed death rate).

Better understanding of mechanisms behind carotid stenosis has challenged the traditional approach to carotid endarterectomy (CEA) as the gold standard for stroke prevention in symptomatic and asymptomatic carotid disease. For symptomatic patients, the high risk of new early embolic recurrence suggested not delaying surgical removal of the carotid embolic plaque for more than 2 weeks after the acute neurological event. For symptom-free patients management of the carotid stenosis by surgery has been even more debated because of the high likelihood of decreased stroke risks with systematic and intensive use of modern medical therapy including antiplatelets, statins, and antihypertensive drugs. However, in supporting this modern approach to carotid stenosis the sudden and often unpredictable nature of its acute manifestation (i.e. the embolization from a “high-risk” carotid plaque resulting in stroke) for both already or never symptomatic carotid patients remains a challenge. Emerging evidence has highlighted the role of inflammatory markers, such as vascular cell adhesion molecules (VCAMs), selectin, chemokines, and proteases (e.g. metalloproteinases), for their potential in triggering a previous quiescent atherosclerotic plaque. In this perspective, cell-derived membrane microparticles (MPs) are among the newest biomarkers suggested for their effect on triggering atherosclerotic plaque. MPs, also known as “microvescicles” or “ectosomes”, are large (50e1000 nm diameter) extracellular vesicles surrounded by a phospholipid bilayer that are released into extracellular space or circulation by direct budding from the plasma membrane of multiple lines of activated cells including platelets, endothelial cells, and leukocytes. In this issue of the European Journal of Vascular and Endovascular Surgery, Wekesa et al. performed a caseecontrol pilot study analyzing levels of endothelial MPs and platelet MPs in addition to other atherosclerotic molecular biomarkers in plasma from 42 patients undergoing CEA for symptomatic (n 1⁄4 37) and asymptomatic (n 1⁄4 4) carotid stenosis patients (cases) and from 73-age and sex-matched patients without carotid

Objectives:To evaluate whether preoperative CT evidence of brain infarction is associated with an increased risk of early and late stroke and death in patients undergoing CEA.Design:Retrospective clinical study.Materials and methods:We evaluated 844 CT scanning records from 893 patients undergoing CEA from 1986–1994: 43% (367) CT positive for cerebral infarction and 57% (477) negative. Univariate and multivariate analysis was performed for risk factors and preoperative symptoms in patients with positive and negative CT scans, and Kaplan Meier survival curves for late events.Results:A positive CT was significantly more frequent in males vs. females (p < 0.0001; O.R. 2.52; C.I. 1.73–3.73), diabetics vs. non-diabetics (p = 0.03; O.R. 1.52; C.I. 1.03–2.26), symptomatics vs. asymptomatics (p < 0.001; O.R. 2; C.I. 1.93–3.53) and contralateral occlusion vs. patency (p < 0.001; O.R. 2; C.I. 1.30–3.10). The perioperative disabling stroke/death rate was higher in patients with a positive CT (p = 0.002; O.R. 6.27; C.I. 1.73–34.20); in asymptomatic patients this difference was striking (5 patients vs. 0, p = 0.0002). Multiple logistic regression analysis for risk factors, CT findings, symptoms preceding surgery, and congruity of brain infarction confirmed a significantly higher incidence of perioperative stroke/death rate (p = 0.003; O.R. 6.37; C.I. 5.12–7.63) and early and late stroke (p = 0.02; O.R. 1.95; C.I. 1.38–2.53) and death (p = 0.0005; O.R. 2.38; C.I. 1.89–2.88) in patients with brain lesions. After 7 years, the survival rate (p = 0.0009) and stroke-free interval (p = 0.003) were lower in patients with a positive CT. After 5 years, in asymptomatic patients the survival rate (p = 0.003) and stroke-free interval (p = 0.01) were lower in the positive CT group.Conclusions:A positive CT finding, regardless of congruity of the lesion, should be regarded as an indicator of an increased risk of stroke and death in patients scheduled for carotid surgery, especially in those with asymptomatic stenosis.

Objectives: To analyse whether contralateral occlusion represents an additional perioperative risk factor in carotid endarterectomy (CEA), and whether long-term survival after surgery in patients with contralateral occlusion differs from that of patients without. Design: Retrospective clinical study. Setting: Vascular Surgery Unit, Department of Surgery, University of Perugia, Perugia, Italy. Materials: Fifty-five patients with carotid stenosis and contralateral occlusion undergoing CEA (Group I) were compared with 110 patients (Group II), without contralateral occlusion selected from a cohort of 367 patients with a patent contralateral artery, matched for gender, age and ipsilateral symptoms. Chief outcome measures: Perioperative stroke/death rate at 30 days and minor complications in Group I vs. Group II over a mean follow-up of 38 months. Main results: The perioperative stroke/death rate at 30 days was 0% in Group I and 2.7% in Group II ( p = 0.6) while minor complications amounted to 11% in Group I and 5% in Group II ( p = 0.2). Survival rates of patients free from stroke, using Kaplan Meier curves, were 79.4% in Group I and 83.3% in Group II ( p = 0.4); stroke free rates were 92.8% and 94.3% in Groups I and II, respectively. The incidence of late stroke, fatal or not, in patients who had undergone CEA with contralateral obstruction was the same as in similarly operated patients without contralateral obstruction (7% vs. 6%). However, the incidence of late vascular death, exemplified by a crude rate of 14% vs. 6% ( p = 0.1; O.R. = 2.50; C.I. = 0.77–8.25) was greater in patients with contralateral occlusion. Conclusions: In this study, CEA in patients with contralateral occlusion was not associated with an increased perioperative morbidity/mortality rate. The higher incidence of vascular death in the late follow-up of patients with contralateral carotid occlusion, although not statistically significant, could indicate the presence of more severe systemic vascular disease.

Recent expansion of endovascular techniques for the treatment of infrapopliteal artery disease has increased the expectation to realistically provide a safer, easier, quicker and effective therapy for many patients with critical limb ischaemia (CLI). Nevertheless, due to the limited numbers, spread among a variety of different techniques, centres and diseases (extension and severity) and the recent introduction (not allowing to validate durability of the results), these novel approaches have still not proved to substantially improve outcomes and remain under investigation in ongoing studies. Periprocedural risk exposure and predictability of success/ failure for the leg with these new approaches in CLI patients remain largely uncertain. Failure rate of distal leg revascularisation techniques relies on several factors (location, extension and severity of artery lesion, run-off status, plantar arch integrity, calcification, diabetes, local status, infection, gangrene, etc.) or, most likely, on a combination of these. A number of scoring systems have been usefully applied to predict outcome after aortic aneurysm or cardiac surgery, while similar methods are lacking in the more challenging field of revascularisation in the legs, with only a few recently conceived.1 In this issue of EJVES, a Japanese experience from Iida et al. proposed a new anatomical score to predict the 2-year major adverse limb event (MALE), defined as freedom from major amputation or any re-intervention after angioplasty of isolated infrapopliteal lesions in patients with CLI.2 By using this score system adopted from cardiac experience (SYNTAX angiographic score for coronary vessel)3 and thereby including only anatomical predictability criteria, the authors were able to individuate limbs with infrapopliteal lesions at high likelihood of unsuccessful endovascular treatment. According to Iida et al. lesion calcification, target vessel diameter 300 mm and no below-the-ankle run-off were positively associated with MALE by multivariate analysis. Over a total of 1057 infrapopliteal angioplasty procedures, freedom fromMALE at 2 years rates were 59% in limbs with only one of these adverse risk factors, but only 29% for limbs with three or four adverse predictors. Even though the authors tested exclusively simple balloon angioplasty and nomore sophisticated techniques for infrapopliteal revascularisation, their system scoremay help identify legs with CLI that can improve less from endovascular therapy and should be

In an era where significant progress in endovascular technologies has drastically altered the treatment paradigm for patients with femoro-popliteal occlusive disease and catheter-based interventions have become the initial treatment of choice in many patients with intermittent claudication or critical limb ischemia (CLI), surgical revascularization of the lower leg is performed less frequently but still remains the reference for treatment due to demonstrated durability and efficacy. This has been endorsed by the recent results form the Scandinavian Propaten study, a large multicenter randomized trial analyzing outcomes of PTFE grafts with heparin bonded luminal surface compared to ordinary pure PTFE grafts in patients with peripheral disease. After randomizing 569 patients through eleven Scandinavian centers, Lindholt et al. found that the use of heparin bounded PTFE grafts was associated with a significant decrease of primary graft failure by 37% at 1 year. Risk reduction was particularly evident (50%) in the subgroups of patients with CLI and with femoro-popliteal by-pass. The first lesson from this recent study is that surgery is no more considered competitor of medical therapy. For many vascular diseases medicine and surgery are today the best companions to reach and optimize the same goals. Vascular research for peripheral disease is rapidly moving forward with sophisticated and innovative combinations of

The early results of the Arbiter 2 study, published in this issue of EJVES, showed as recent improvements gained with newgeneration aortic stentgrafts allowed endovascular aneurysm repair (EVAR) to better deal with difficult anatomy. The Aorfix modular device (Lombard Medical Technologies) was shown to be successfully applied in aneurysmswith excessive neck angulation, mainly 75 and even >90 (!). Unfortunately, only 30 cases were studied in this pilot study and assessment stopped early, providing only short-term results. Despite the extremely adverse anatomy, initial technical success was achieved in 93.3% because of two immediate migrations. No subsequent migrations were observed; however, procedure was associated with 3% perioperative mortality, 17% morbidity and approximately 7% type I endoleak and 10% mortality at 6 months. At this point, will any aggressive refinement in stentgraft technology to treat abdominal aortic aneurysms (AAA) with unfit anatomy be worthwhile? Some important messages could be provided by the Arbiter 2 study to this regard. The first is that technology for EVAR stentgraft has substantially improved in the last few years, providing models with certainly superior results, not hoped before. Fortunately, EVAR, even in its maturity, is ‘a work in

Rupture of an abdominal aortic aneurysm (AAA) is unpredictable, rarely foreshowed by warning symptoms but lethal in 90%. There is now compelling evidence that the risk of rupture in small aneurysms is much lower than what was previously thought. The systematic review of Powell et al. in this issue of European Journal of Vascular and Endovascular Surgery (EJVES) adds substantially to the published data on the rupture rate of small aneurysms. However, the available heterogeneous data did not allow the authors to provide strong suggestions, one of the major issues complicating the understanding of rupture in small AAAs being the dissimilar reporting of rates and diameter ranges over various follow-up lengths on an event rate that changes (and probably not constantly) over time. After retrievingmore than ten thousands of articles, only 14 were eligible for the final analysis; but only seven selected studies (including 5934 AAAs) reported on conditional followupdatawhereaneurysmsizewasknownat the timeof rupture. The authors calculated that the risk of rupture in aneurysms between 3.5 and 5.5 cm in diameter is extraordinarily low and ranges from 0 to 1.61 ruptures per 100 person-years. Of note, six out of the seven studies reported rates below 0.5 per 100 person-years; the only one showing higher rate analysed exclusively 5.0e5.4-cm aneurysms.