Small abdominal aortic aneurysms (AAA) have historically been defined as those measuring less than 5.5 centimeters in men and 5.0 centimeters in women. At this size threshold, large randomized controlled trials have failed to identify a survival advantage to repair, and as a result all major guidelines recommend ongoing surveillance for small abdominal aortic aneurysms without high-risk features. Despite these guidelines, significant limitations in current data exist, particularly as women and persons of color remain widely underrepresented in the practice defining randomized controlled trials as outlined in Table 1. Additionally, optimal size threshold for saccular aneurysms remains elusive. Nonetheless, open and endovascular repair for small aneurysms is commonplace with as many as 49% of repairs performed for AAAs which do not reach this size criteria. While a reasonable rate of surgical repair should be expected to account for the treatment of saccular aneurysms as well other high-risk features, current practice patterns reflect higher rates of elective repair for small aneurysms than should be expected and raise concerns over the appropriateness of such treatment. Further research is critical to identify the optimal treatment of small aneurysms in women and identify what proportion of repair of aneurysms smaller than 5.5cm should be reasonably expected.