Surprisingly, some patients won’t do as told and have less events

Today  endovascular aneurysm repair (EVAR) is the preferred option to treat patients with abdominal aortic aneurysms, even though studies have shown reintervention rate is around 20% at 5 years. Consequently, guidelines recommend life EVAR surveillance imaging to identify and treat eventual leaks and prevent aneurysms from growing and eventually rupturing.

There are several population and observational studies that show a great number of patients simply “forget” the importance of EVAR surveillance. However, we know little about its long term safety implications and event incidence.

Read also: Coronary Disease Works as a 30-Day Predictor in TAVR.

This meta-analysis, carried out to collect data in this regard, included 13 studies and 40730 patients eligible for systematic review. 7 of these studies and 14311 patients were eligible to report mortality.

The estimated EVAR surveillance non-compliance rate reached 42% (CI 95%; 28 to 56%).

There were no significant differences in terms of all-cause mortality at one year (OR 5.77, CI 95% 0.74 to 45.14), at 3 years (OR 2.28, CI 95% 0.92 to 5.66) or at 5 years (OR 1.81, CI 95% 0.88 to 2.74) after EVAR between compliant vs. non-compliant patients. Neither were there differences in aortic aneurysm related mortality at 5 years. (OR 1.47, CI 95% 0.99 to 2.19).

Read also: Surgical or Percutaneous Management of Mitral Leak.

As expected, reintervention rates were significantly higher for patients compliant with the surveillance imaging scheme; up to 5 times higher.

Conclusion

This systematic review suggests EVAR surveillance compliant patients treated for aortic aneurysm have a much higher reintervention rate that do not translate into events reduction, such as all-cause mortality or aortic aneurysm related mortality, compared to non-compliant patients. 

Editorial Comment

In general, post EVAR surveillance is based on arbitrary recommendations each company makes for their devices. This varies from one device to another and could create enough digression to explain the outcomes of this study. 

We have recently published in our page a very interesting study on this topic which coined the term “minimal appropriate surveillance”. This scheme is defined as an abdominal CT or ECG within 90 days after procedure, and every 15 months after that (far less aggressive than we normally recommend).

Compliance with this minimal appropriate surveillance scheme has been associated with lower mortality, compared to non-compliance, and decreased mortality: the longer patients comply with this scheme, the lower the mortality rate.

The only way to get a final answer would be to randomize patients to an imaging surveillance protocol vs. a clinical surveillance protocol, but it seems such study won’t be conducted any time soon. 

Título original: The Implications of Non-compliance to Endovascular Aneurysm RepairSurveillance: A Systematic Review and Meta-analysis.

Referencia: Matthew Joe Grima et al. Eur J Vasc Endovasc Surg. 2018 Jan 4. Epub ahead of print.

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