Secondary interventions following endovascular aneurysm repair (EVAR) and the enduring value of graft surveillance

Abstract

Objective: Lifelong imaging surveillance is currently recommended for all patients following endovascular aortic aneurysm repair (EVR). The modality, timing and overall necessity of surveillance has recently been brought into question. This review reports contemporary secondary intervention rates and explores surveillance imaging pick-up rates and reports the evidence supporting modified EVR surveillance programs.

Design: Systematic review of literature (2002-2009) and meta-analysis of Kaplan-Meier re-intervention-free survival estimates.

Results: 32 Papers were included in final analysis. 17,987 EVR cases were reported. Crude annual secondary intervention rates from the US population registries were 3.7%/year (range 1.7-4.3%). Combined re-intervention-free survival estimates, from 14 series (10,365 cases), demonstrated a linear progression with 89.9%, 86.9% and 81.5% of grafts without secondary procedures at 2, 3 and 5 years respectively. 3 Reports (1249 cases) differentiated between interventions directed by surveillance or outside surveillance protocols. Surveillance imaging alone initiated the secondary interventions in 1.4-9% of cases; >90% of EVR cases received no benefits from surveillance scans.

Discussion: Some format of surveillance following EVR probably remains necessary despite a reduction in secondary interventions with modern stent-grafts. Surveillance should be targeted at those stent-grafts and patients at high risk of complications. Further work is justified to identify this group.