Reliability and Safety of Individualized Follow-up Based on the 30-day Computed Tomography Angiogram after Endovascular Aneurysm Repair

Abstract

Background: Most patients undergo uneventful surveillance after endovascular aneurysm repair (EVAR), and therefore, unmodified surveillance protocols are ineffective. An example of a modified follow-up protocol was introduced by the European Society for Vascular Surgery (ESVS) in January 2019. One feature of this protocol is that for the patients with adequate sealing and without any detectable endoleak at 30 days, the next scheduled follow-up could be at 5 years. The purpose of this study was to analyze retrospectively the applicability of this protocol.

Methods: Between 2005 and 2013, 348 patients were treated electively for abdominal aortic aneurysm (AAA) with a standard EVAR. All patients were annually followed and they were retrospectively fitted into the ESVS follow-up protocol based on imaging findings.

Results: The mean follow-up was 74 months (standard error 2.1; range, 0-165 months). Thirty-day mortality was 1.1% (n = 4). Imaging data for those surviving the first 30 days were available for 98.8% (n = 340) subjects. At a 1-month control examination, 79.3% (n = 276) of the patients had no detectable endoleak and sealing was adequate (≥1 cm). Of those patients, with the lowest risk, 11.6% (n = 32) required reintervention for graft-related complication during the next 5 years. In all, complications requiring treatment that would have been missed by following the suggested protocol included type 1A endoleak (n = 7), type 1B (n = 10), type 2 (n = 7), migration (n = 2), thrombosis (n = 10), kinking (n = 1), and ruptured AAA (n = 6). The sensitivity of 30-day computed tomography angiogram was 34.9% (95% confidence interval 21.01-50.93%) and specificity 83.3% (95% confidence interval 78.57-87.41%) for finding significant complications during first 5 years.

Conclusions: Based on our findings, by following the example ESVS follow-up protocol, we would have missed major life-threatening complications. Significant stent-graft failures occur during the first 5 years, even for those with noncomplicated post-EVAR findings in the first computed tomography angiogram at 1 month.