This study states that Treating abdominal aortic aneurysm (AAA) below the guideline thresholds is discouraged by randomized trial-level evidence. We sought to examine physician practice patterns of endovascular aneurysm repair (EVAR) performed for small AAAs in the United States. We included all elective EVARs reported in the Vascular Quality Initiative database (2012-2018). Small AAAs were defined as a maximum diameter <5.5 cm in men or <5.0 cm in women. We excluded physicians who performed fewer than five EVARs during the study period. We used multivariable logistic regression with clustering by physician to assess the association of region with EVAR for small AAAs after adjusting for patient characteristics. There were 37,080 EVARs performed by 1124 physicians in the study. The median number of EVARs performed per physician was 22 (interquartile range, 11-43) with a maximum of 241. Overall, 40.7% (n = 15,075) of EVARs were performed for small AAAs. The physician median percentage EVARs performed for small AAAs was 40%. There is wide variation in adherence to guideline sizes for AAA treatment in the United States, with 40% of EVARs being performed outside of practice guidelines. Physicians in the South treated small AAAs more frequently than those in other regions. This practice is costly to the health care system with no proven benefit to patients.

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