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Schutt J, Bohr NL, Cao K, Pocivavsek L, Milner R. Social Determinants of Health Factors and Loss-To-Follow-Up in the Field of Vascular Surgery. Ann Vasc Surg 2024; 105:316-324. [PMID: 38609010 DOI: 10.1016/j.avsg.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/27/2023] [Accepted: 01/21/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND It is estimated that 22-57% of vascular patients are lost to follow-up (LTF) which is of concern as the Society of Vascular Surgery recommends annual patient follow-up. The purpose of this report was to identify social determinants of health factors (SDoH) and their relationship to LTF in vascular patients. METHODS The methods employed were a systematic literature review of 29 empirical articles and a retrospective quality improvement report with 27 endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) patients at the University of Chicago. RESULTS The systematic literature review resulted in 2,931 articles which were reduced to 29 articles meeting the inclusion criteria. Demographic variables were more frequently cited than SDoH factors, but the most common were smoking, transportation, and socioeconomic status/insurance. Additionally, 176 EVAR and TEVAR patients were called resulting in 27 patients who completed a SDoH questionnaire. Twenty-six percent indicated they had missed at least 1 appointment with the top reasons being work or family responsibilities. Due to limited patient size no statistical analyses were performed, but frequencies of responses to SDoH questions were reported to augment the existing limited literature and guide future research into variables such as one's ability to pay for basics like food or mortgage. CONCLUSIONS SDoH factors are important yet understudied aspects of endovascular repairs that require more research to understand their impact on vascular surgery follow-up rates and outcomes. Additional research is needed as lack of consideration of such factors may impact the generalizability of existing research and such knowledge may help in informing clinician treatment plans.
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Affiliation(s)
- Jonathon Schutt
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL.
| | - Nicole L Bohr
- Department of Nursing Research, UChicago Medicine, Chicago, IL; Department of Surgery, University of Chicago, Chicago, IL
| | - Kathleen Cao
- Department of Surgery, University of Chicago, Chicago, IL
| | | | - Ross Milner
- Department of Surgery, University of Chicago, Chicago, IL
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Rašiová M, Koščo M, Pavlíková V, Hudák M, Moščovič M, Kočan L. Predictors of overall mortality after endovascular abdominal aortic repair - A single centre study. Vascular 2024:17085381241262350. [PMID: 38872254 DOI: 10.1177/17085381241262350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
OBJECTIVES A current and ongoing challenge is to reduce patient mortality after endovascular abdominal aortic repair (EVAR). This study aimed to assess the predictors of all-cause mortality after EVAR. METHODS Data regarding the demographic characteristics, comorbidities, laboratory values, selected anatomical factors, post-EVAR treatment, surveillance and complications of patients who underwent elective EVAR for non-ruptured abdominal aortic aneurysm (AAA) between January 2010 and January 2021 were evaluated. Mortality was assessed until 10 October 2023. Multivariate analyses were performed after adjusting for age, hypertension, diabetes mellitus, dyslipidaemia, sex, smoking, number of lumbar arteries, patency of inferior mesenteric artery (IMA), IMA diameter and reinterventions. RESULTS This study included 196 patients (183 men and 13 women) with a mean age of 72.4 ± 7.67 years. The overall mortality rate during a mean follow-up period of 5.75 ± 3.1 years was 50.0% (N = 98). The 2-, 5- and 10-year mortality rates were 9.7%, 32.0% and 66.6%, respectively. The mortality rates decreased by 59% in patients with reinterventions (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.23-0.73; p = .002) and by 59% in patients treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (HR: 0.41; 95% CI: 0.26-0.66; p < .001). Chronic anticoagulation was associated with 2.09-fold higher mortality (HR: 2.09; 95% CI: 1.19-3.67; p = .010), and coronary artery disease (CAD) was associated with 1.74-fold higher mortality (HR: 1.74; 95% CI: 1.09-2.78; p = .021). Pre-EVAR AAA diameter and 1-year post-EVAR sac diameter were positively associated with mortality (HR: 1.05; 95% CI: 1.03-1.08; p < .001, and HR: 1.05; 95% CI: 1.03-1.07; p < .001, respectively), that is, an increase of pre-EVAR and/or 1-year post-EVAR AAA diameter by 1 mm was associated with a 5% higher risk of all-cause mortality. CONCLUSIONS Reinterventions and treatment with ACE inhibitors or ARBs may be associated with decreased post-EVAR mortality. A greater pre-EVAR, a post-EVAR AAA diameter, CAD and chronic anticoagulation were associated with higher all-cause mortality post-EVAR.
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Affiliation(s)
- Mária Rašiová
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Martin Koščo
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Veronika Pavlíková
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Marek Hudák
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Matej Moščovič
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Ladislav Kočan
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
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Schmidt FP, Geyer M, Sotiriou E, Ardic Y, Sadegh P, Schulz E, Münzel T, von Bardeleben RS. Guideline-endorsed follow-up after percutaneous valve therapies-non-attendance of TAVI and MitraClip patients. Herz 2024:10.1007/s00059-024-05245-2. [PMID: 38743296 DOI: 10.1007/s00059-024-05245-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Percutaneous valve therapies (PVT) are performed on a large number of patients. With increasing procedural volume, the need for follow-up has also increased. Follow-up in the heart valve clinic is endorsed by recent guidelines but utilization is unknown, making resource allocation in the clinic difficult. Central follow-up in valve centers may not be feasible for all patients in the future. METHODS In our center, follow-up for PVT patients is scheduled at 1 month and 12 months after the index procedure. Patients are reminded of their appointment by invitation letters or phone calls. We analyzed 150 consecutive patients who underwent transcutaneous aortic valve implantation (TAVI) and MitraClip implantation (n = 300) at our center. RESULTS At 1 month, 72.7% of patients attended their follow-up, while at 12 months the rate dropped to 58%. Patients who underwent TAVI were older than the MitraClip patients (82.7 vs. 76.1 years) but had lower mean logEuroSCORE (22.6% vs. 25.9%). There was no significant difference in 1‑year mortality between TAVI and MitraClip patients (20% vs. 17.3%). By contrast, the rate of missed follow-up visits was higher for TAVI compared to MitraClip patients (52% vs. 33.3%; p = 0.002). Female patients less frequently attended follow-up (p = 0.005), whereas age, EuroSCORE, NYHA class, ejection fraction, and health status (EQ-5DVAS) were not predictors of attendance in multivariable analysis. Although the result of the EQ-5D assessment was not associated with mortality or attendance, completing the questionnaire was associated with overall survival (p < 0.001). CONCLUSION In our heart valve clinic, we observed a high percentage of missed follow-up appointments (42% at 12 months) despite a structured follow-up plan. Factors significantly associated with non-attendance in multivariable analysis were female gender and having a TAVI rather than MitraClip. Future follow-up concepts should take such findings into account, and decentralized approaches need to be explored.
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Affiliation(s)
- Frank Patrick Schmidt
- Center for Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany.
- Inneren Medizin 3, Klinikum Mutterhaus der Borromäerinnen, Feldstr. 16, 54290, Trier, Germany.
| | - Martin Geyer
- Center for Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Efthymios Sotiriou
- Inneren Medizin 3, Klinikum Mutterhaus der Borromäerinnen, Feldstr. 16, 54290, Trier, Germany
| | - Yasemin Ardic
- Center for Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Pantea Sadegh
- Center for Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | | | - Thomas Münzel
- Center for Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
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Antoniou GA, Kontopodis N, Rogers SK, Golledge J, Forbes TL, Torella F, Verhagen HJM, Schermerhorn ML. Editor's Choice - Meta-Analysis of Compliance with Endovascular Aneurysm Repair Surveillance: The EVAR Surveillance Paradox. Eur J Vasc Endovasc Surg 2023; 65:244-254. [PMID: 36273676 DOI: 10.1016/j.ejvs.2022.10.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/24/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the survival of patients who attended surveillance after endovascular aneurysm repair (EVAR) with those who were non-compliant. DATA SOURCES MEDLINE and Embase were searched using the Ovid interface. REVIEW METHODS A systematic review was conducted complying with the PRISMA guidelines. Eligible studies compared survival in EVAR surveillance compliant patients with non-compliant patients. Non-compliance was defined as failure to attend at least one post-EVAR follow up. The risk of bias was assessed with the Newcastle-Ottawa scale, and the certainty of evidence using the GRADE framework. Primary outcomes were survival and aneurysm related death. Effect measures were the hazard ratio (HR) or odds ratio (OR) and 95% confidence interval (CI) calculated using the inverse variance or Mantel-Haenszel statistical method and random effects models. RESULTS Thirteen cohort studies with a total of 22 762 patients were included. Eight studies were deemed high risk of bias. The pooled proportion of patients who were non-compliant with EVAR surveillance was 43% (95% CI 36 - 51). No statistically significant difference was found in the hazard of all cause mortality (HR 1.04, 95% CI 0.61 - 1.77), aneurysm related mortality (HR 1.80, 95% CI 0.85-3.80), or secondary intervention (HR 0.66, 95% CI 0.31 - 1.41) between patients who had incomplete and complete follow up after EVAR. The odds of aneurysm rupture were lower in non-compliant patients (OR 0.63, 95% CI 0.39 - 1.01). The certainty of evidence was very low for all outcomes. Subgroup analysis for patients who had no surveillance vs. those with complete surveillance showed no significant difference in all cause mortality (HR 1.10, 95% CI 0.43 - 2.80). CONCLUSION Patients who were non-compliant with EVAR surveillance had similar survival to those who were compliant. These findings question the value of intense surveillance in all patients post-EVAR and highlight the need for further research on individualised or risk adjusted surveillance.
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Affiliation(s)
- George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Greece
| | - Steven K Rogers
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia; Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre and University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francesco Torella
- Liverpool Vascular & Endovascular Service, Liverpool, UK; School of Physical Sciences, University of Liverpool, Liverpool, UK; Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Hence J M Verhagen
- Division of Vascular and Endovascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA
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Editor's Choice - Post-operative Surveillance and Long Term Outcome after Endovascular Aortic Aneurysm Repair in Patients with an Initial Post-operative Computed Tomography Angiogram Without Abnormalities: the Multicentre Retrospective ODYSSEUS Study. Eur J Vasc Endovasc Surg 2022; 63:390-399. [PMID: 35181224 DOI: 10.1016/j.ejvs.2021.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 11/01/2021] [Accepted: 11/14/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Lifelong imaging surveillance is recommended following endovascular aneurysm repair (EVAR). This study aimed to examine the association between adherence to post-operative surveillance and survival and secondary interventions in patients with an initial post-operative computed tomography angiogram (CTA) without abnormalities. METHODS All consecutive patients undergoing EVAR for intact abdominal aortic aneurysm (AAA) in 16 hospitals between 2007 and 2012 were identified retrospectively, with follow up until December 2018. Patients were included if the initial post-operative CTA showed no types I - III endoleak, kinking, infection, or limb occlusion. Discontinued follow up was defined as at least one 16 month period in which no imaging surveillance was performed. Primary outcomes were aneurysm related mortality and secondary interventions, and secondary outcome all cause mortality. Kaplan-Meier analysis was used to estimate survival, and Cox regression analyses to identify the association between independent variables and outcome. Sensitivity analyses were performed by varying the definition of continued yearly follow up. The study protocol was published (bmjopen-2019-033584). RESULTS 1 596 patients (552 continued, 1 044 discontinued follow up) were included with a median (interquartile range) follow up of 89.1 months (52.6). Cumulative aneurysm related, overall, and intervention free survival was 99.4/94.8/96.1%, 98.5/72.9/85.9%, and 96.3/45.4/71.1% at 1, 5, and 10 years, respectively. American Society of Anesthesiologists (ASA) classification (ASA IV hazard ratio [HR] 3.810, 95% confidence interval [CI] 1.296 - 11.198), increase in AAA diameter (HR 3.299, 95% CI 1.408 - 7.729), and continued follow up (HR 3.611, 95% CI 1.780 - 7.323) were independently associated with aneurysm related mortality. The same variables and age (HR 1.063 per year, 95% CI 1.052 - 1.074) were significantly associated with all cause mortality. No difference in secondary interventions was observed between patients with continued vs. discontinued follow up (89/552; 16% vs. 136/1044; 13%; p = .091). Sensitivity analyses showed worse aneurysm related and overall survival in patients with continued follow up. CONCLUSION Discontinued follow up is not associated with poor outcomes. Future prospective studies are indicated to determine in which patients imaging follow up can be safely reduced.
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Li B, Khan S, Salata K, Hussain MA, de Mestral C, Greco E, Aljabri BA, Forbes TL, Verma S, Al-Omran M. A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm. J Vasc Surg 2019; 70:954-969.e30. [DOI: 10.1016/j.jvs.2019.01.076] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/11/2019] [Indexed: 01/09/2023]
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de Mik SML, Geraedts ACM, Ubbink DT, Balm R. Effect of Imaging Surveillance After Endovascular Aneurysm Repair on Reinterventions and Mortality: A Systematic Review and Meta-analysis. J Endovasc Ther 2019; 26:531-541. [PMID: 31140361 PMCID: PMC6630065 DOI: 10.1177/1526602819852085] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Purpose: To study the effects of imaging surveillance after endovascular aortic repair (EVAR) on reintervention and mortality. Materials and Methods: A systematic review was conducted comparing complication rates in EVAR patients compliant with the imaging surveillance protocol vs partially or noncompliant patients. Two authors independently selected articles and performed quality assessment and data extraction. Risk differences for reintervention and mortality between compliant and partially/noncompliant patients were meta-analyzed. The pooled risk difference (RD) is reported with the 95% confidence interval (CI). The review protocol is registered at Prospero (CRD42017080494). Results: A total of 11 cohort studies involving 21,838 patients were included. Studies differed in imaging, their surveillance protocols, and definitions of compliance subgroups. Median follow-up was 31.7 months (interquartile range 29.8, 49.3). The overall reintervention rate was 5%, while the overall mortality was 31%. The RD for the reintervention rate was 4% (95% CI 1% to 7%) in favor of partial/noncompliance [number needed to harm 25 (95% CI 14 to 100)], while mortality showed a nonsignificant RD of 12% (95% CI −2% to 26%) in favor of partial/noncompliance. Two studies reported that 41% to 53% of reinterventions were performed for complications detected through imaging surveillance; the other events were detected through patient symptoms. Conclusion: Patients who are compliant with imaging surveillance appear to undergo more reinterventions than those who are partially or noncompliant. However, imaging surveillance does not seem to protect against mortality. This suggests that the recommended yearly imaging surveillance may not be beneficial for all EVAR patients.
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Affiliation(s)
- Sylvana M L de Mik
- 1 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam, the Netherlands
| | - Anna C M Geraedts
- 1 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam, the Netherlands
| | - Dirk T Ubbink
- 1 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam, the Netherlands
| | - Ron Balm
- 1 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam, the Netherlands
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Doshi S, Eisenberg N, Bailey S, Annamalai G, Roche-Nagle G. Adherence to recommended imaging surveillance of acutely presenting Stanford type-B aortic dissections. Vascular 2019; 27:524-534. [PMID: 30961469 DOI: 10.1177/1708538119841453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Acutely presenting Stanford type B aortic dissections (type-B AD) primarily receive medical or endovascular management and require lifelong imaging surveillance. CT and MR imaging are the best modalities to assess early indications of potentially fatal developments. Published guidelines recommend that imaging occur at 1, 3, 6, and 12 months following acute presentation, and annually thereafter. This study evaluates adherence to recommended imaging surveillance for newly presenting type-B AD patients at a tertiary hospital. Methods A retrospective review of patients presenting with a new, acute type-B AD between January 2010 and March 2017 was performed. Patient demographics, type-B AD admission details, and medical histories were obtained from electronic and paper chart reviews. CT and MR images were reviewed, and aortic sizes were measured by two independent radiologists. Patients without a clinical visit or type-B AD surveillance imaging for greater than 15 months were considered lost to follow-up after their last appointment. Overall clinical follow-up and adherence to recommended were analyzed using Kaplan–Meier graphs. Log-rank analysis assessed factors increasing risk of poor clinical follow-up and adherence to surveillance guidelines. Results Sixty-two patients (38 male, 24 female) were included. At the time of index admission, median age was 62 (SD 14), and median aortic diameter was 45 mm (SD 11.2). Median duration of overall follow-up was 24 months. Kaplan–Meier analysis of overall follow-up, censoring death, and external follow-up, indicated clinical follow-up rates of 87.1% (SE = 4.3%) at 3 months, 85.2% (SE = 4.6%) at 6 months, 77.5% (SE = 5.6%) at 12 months, and 63.8% (SE = 8.1%) at 60 months. Similar analysis of adherence to recommended imaging surveillance revealed rates of 56.5% (SE 6.3%) at 3 months, 36.9% (6.7%) at 6 months, 21.5% (6.5%) at 12 months, and 12.9% (6.1%) at 24 months. Log-rank analysis indicated that specialty arranging follow-up – medical ( n = 24) versus surgical ( n = 38) – did not impact overall follow-up or adherence to recommended guidelines. Similarly, none of patient distance to hospital, medical versus endovascular intervention, initial dissection size, smoking history, or additional medical/demographic impacted these outcomes. Conclusions At our institution, we identified a gap between imaging surveillance following type-B AD and adherence to recommended, published guidelines. This was consistent across all type-B AD patients with no subset in isolation. Multiple opportunities for quality improvement exist to facilitate improved compliance with published guidelines.
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Affiliation(s)
- Sachin Doshi
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Naomi Eisenberg
- Department of Vascular Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Shawn Bailey
- Department of Interventional Radiology, Mount Sinai Hospital Toronto, ON, Canada
| | - Ganesan Annamalai
- Department of Interventional Radiology, Mount Sinai Hospital Toronto, ON, Canada
| | - Graham Roche-Nagle
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Vascular Surgery, Toronto General Hospital, Toronto, ON, Canada
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Grima MJ, Karthikesalingam A, Holt PJ, Kerr D, Chetter I, Harrison S, Sayers R, Roy I, Vallabhaneni SR, Dominic P, Bachoo P, Griffin J, Lewis D, Hardman J, Rihan A, Brooks M, Woodburn K, Godfrey D, Nordon I, Vidal-Diez A, Stenson K, Bahia S, Patterson B, Oladokun D, De Bruin J, Loftus I, Thompson MM, Lowe C, Ashrafi M, Ghosh J, Ashleigh R. Multicentre Post-EVAR Surveillance Evaluation Study (EVAR-SCREEN). Eur J Vasc Endovasc Surg 2019; 57:521-526. [DOI: 10.1016/j.ejvs.2018.10.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/27/2018] [Indexed: 11/29/2022]
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Tyagi SC, Calligaro KD, Fukuhara S, Greenberg J, Pineda DM, Zheng H, Dougherty MJ, Troutman DA. Patient satisfaction and chronic illness are predictors of postendovascular aneurysm repair surveillance compliance. J Vasc Surg 2018; 69:1066-1071. [PMID: 30301686 DOI: 10.1016/j.jvs.2018.06.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Although lifelong surveillance is recommended by the Society for Vascular Surgery for patients undergoing endovascular aneurysm repair (EVAR) reported that compliance with long-term follow-up has been poor. We sought to identify factors that predict compliance with EVAR surveillance through analysis of patient variables and post-EVAR questionnaire results. METHODS We analyzed 28 patient variables gathered from our computerized registry, patient charts, and phone questionnaires of patients who underwent EVAR between January 1, 2010, and December 31, 2014. These factors included patient demographics, education, postoperative complications, satisfaction with vascular surgery care, transportation mode, distance to our medical center, and living situation. Compliance was defined as a patient who underwent the most recent recommended follow-up surveillance study within the prescribed timeframe. Post-EVAR surveillance protocol consisted of office evaluation and duplex ultrasound examination performed in our accredited noninvasive vascular laboratory at 1 week, 6 months, then annually. Computed tomography angiography was obtained only if duplex ultrasound examination suggested endoleak, sac enlargement of more than 5 mm, or a failing limb. RESULTS Of 144 patients who underwent EVAR during this time period, 89 patients (62%) were compliant with the most recent recommended follow-up study. One hundred two patients completed the questionnaire or their families did if patients died or were incapacitated. Of those, 80 were compliant with follow-up and 22 were not. Based on the questionnaires of these 102 patients, estimated compliance at 3 years after EVAR was 69.6 ± 6.0% based on Kaplan-Meier analysis. In the compliant vs noncompliant groups, the estimated 3-year survival rate was 93.2 ± 3.4% vs 52.4 ± 12.7%, respectively (P < .001), and the estimated 5-year survival rate was 83.1 ± 6.4% vs 34.4 ± 13.4%, respectively (P < .001), respectively. However, none of the mortalities observed in the noncompliant group were aneurysm related. Adverse neurologic events after EVAR demonstrated a trend predicting noncompliance after 5 years based on multivariate Cox regression analysis (hazard ratio [HR], 2.57; 95% confidence interval [CI], 0.95-6.90; P = .062). Patient dissatisfaction with their vascular surgeon and hospital care predicted noncompliance with recommended postoperative surveillance (HR, 5.0; 95% CI, 1.52-16.7; P = .008). College education or higher was associated with compliance (HR, 0.28; 95% CI, 0.06-1.23; P = .092). No other variables, including postoperative complications or distance from the hospital, predicted follow-up noncompliance. CONCLUSIONS Patient satisfaction with their vascular surgeon and hospital experience predicted compliance with post-EVAR surveillance regardless of postoperative complications. Noncompliant patients had decreased survival, but mortality and surveillance noncompliance were likely due to disabling chronic disease.
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Affiliation(s)
- Sam C Tyagi
- Section of Vascular and Endovascular Surgery, Department of Surgery, University of Kentucky, Lexington, Ky.
| | - Keith D Calligaro
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Jacques Greenberg
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | - Danielle M Pineda
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | - Hong Zheng
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
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Shiraev TP, Durur E, Robinson DA. Factors Predicting Noncompliance with Follow-up after Endovascular Aneurysm Repair. Ann Vasc Surg 2018; 52:30-35. [DOI: 10.1016/j.avsg.2018.03.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 03/04/2018] [Accepted: 03/26/2018] [Indexed: 11/29/2022]
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Grima MJ, Boufi M, Law M, Jackson D, Stenson K, Patterson B, Loftus I, Thompson M, Karthikesalingam A, Holt P. Editor's Choice - The Implications of Non-compliance to Endovascular Aneurysm Repair Surveillance: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2018; 55:492-502. [PMID: 29307756 PMCID: PMC6481561 DOI: 10.1016/j.ejvs.2017.11.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 11/27/2017] [Indexed: 10/25/2022]
Abstract
OBJECTIVE/BACKGROUND Increasingly, reports show that compliance rates with endovascular aneurysm repair (EVAR) surveillance are often suboptimal. The aim of this study was to determine the safety implications of non-compliance with surveillance. METHODS The study was carried out according to the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An electronic search was undertaken by two independent authors using Embase, MEDLINE, Cochrane, and Web of Science databases from 1990 to July 2017. Only studies that analysed infrarenal EVAR and had a definition of non-compliance described as weeks or months without imaging surveillance were analysed. Meta-analysis was carried out using the random-effects model and restricted maximum likelihood estimation. RESULTS Thirteen articles (40,730 patients) were eligible for systematic review; of these, seven studies (14,311 patients) were appropriate for comparative meta-analyses of mortality rates. Three studies (8316 patients) were eligible for the comparative meta-analyses of re-intervention rates after EVAR and four studies (12,995 patients) eligible for meta-analysis for abdominal aortic aneurysm related mortality (ARM). The estimated average non-compliance rate was 42.0% (95% confidence interval [CI] 28-56%). Although there is some evidence that non-compliant patients have better survival rates, there was no statistically significant difference in all cause mortality rates (year 1: odds ratio [OR] 5.77, 95% CI 0.74-45.14; year 3: OR 2.28, 95% CI 0.92-5.66; year 5: OR 1.81, 95% CI 0.88-3.74) and ARM (OR 1.47, 95% CI 0.99-2.19) between compliant and non-compliant patients in the first 5 years after EVAR. The re-intervention rate was statistically significantly higher in compliant patients from 3 to 5 years after EVAR (year 1: OR 6.36, 95% CI 0.23-172.73; year 3: OR 3.94, 85% CI 1.46-10.69; year 5: OR 5.34, 95% CI 1.87-15.29). CONCLUSION This systematic review and meta-analysis suggests that patients compliant with EVAR surveillance programmes may have an increased re-intervention rate but do not appear to have better survival rates than non-compliant patients.
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Affiliation(s)
- Matthew Joe Grima
- St George's Vascular Institute, St George's Hospital, NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.
| | - Mourad Boufi
- St George's Vascular Institute, St George's Hospital, NHS Foundation Trust, London, UK; Aix-Marseille Université, CNRS, IRPHE UMR 7342, Marseille, France; APHM, Department of Vascular Surgery, University Hospital Nord, Marseille, France
| | - Martin Law
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Dan Jackson
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Kate Stenson
- St George's Vascular Institute, St George's Hospital, NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Benjamin Patterson
- St George's Vascular Institute, St George's Hospital, NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Ian Loftus
- St George's Vascular Institute, St George's Hospital, NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Matt Thompson
- St George's Vascular Institute, St George's Hospital, NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Alan Karthikesalingam
- St George's Vascular Institute, St George's Hospital, NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Peter Holt
- St George's Vascular Institute, St George's Hospital, NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
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A systematic review of surveillance after endovascular aortic repair. J Vasc Surg 2018; 67:320-331.e37. [DOI: 10.1016/j.jvs.2017.04.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/23/2017] [Indexed: 11/17/2022]
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14
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Jasinski PT, Labropoulos N, Christoforatos OG, Tassiopoulos AK. Factors Affecting Follow-Up Compliance in Patients After Endovascular Aneurysm Repair. AORTA (STAMFORD, CONN.) 2017; 5:148-156. [PMID: 29657953 PMCID: PMC5890765 DOI: 10.12945/j.aorta.2017.17.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/15/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate potential factors affecting patient non-compliance after endovascular aneurysm repair. METHOD We performed a retrospective review of patients undergoing elective or emergency endovascular repair for thoracic, abdominal aorta, or iliac artery aneurysm at a single institution from November 2007 to March 2014. Compliance to follow-up at 1, 6, and 12 months was assessed. Factors evaluated included patient demographics, size of aneurysm, distance between the patient's residence and outpatient clinic, urgency of surgery, and time of year in which the follow-up visits were scheduled. RESULTS During the study period, 205 patients (75% male and 25% female) fulfilled the inclusion criteria. One-month mortality was 1.1% for elective procedures and 16.1% for emergency procedures (p = 0.001). Overall mortality at 12 months was 6.3% and 32.3% for elective and emergency procedures, respectively (p = 0.0002). Highest compliance was observed at 1 month, with 184 patients (93%) attending. A significant decrease was seen at 6 (n = 102, 54%) and 12 (n = 89, 48%) months. At the 12-month mark, a larger proportion of minority patients were non-compliant compared with Caucasian patients. Confounders for non-compliance were analyzed using multivariate analysis, and statistical significance was found for widowed marital status (p = 0.008), travel distance >25 miles to the outpatient clinic (p = 0.032), and emergency repair of aneurysms (p = 0.022). CONCLUSION Despite emphasizing the importance of follow-up after endovascular aortic procedures, almost half of the treated patients were non-compliant. Our study identified travel distance, marital status, and urgency of surgery as factors that may affect patients' compliance to scheduled follow-up visits.
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Affiliation(s)
- Patrick T. Jasinski
- Division of Vascular and Endovascular Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | - Nicos Labropoulos
- Division of Vascular and Endovascular Surgery, Stony Brook Medicine, Stony Brook, New York, USA
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15
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de Mestral C, Croxford R, Eisenberg N, Roche-Nagle G. The Impact of Compliance with Imaging Follow-up on Mortality After Endovascular Abdominal Aortic Aneurysm Repair: A Population Based Cohort Study. Eur J Vasc Endovasc Surg 2017; 54:315-323. [DOI: 10.1016/j.ejvs.2017.06.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 06/25/2017] [Indexed: 11/30/2022]
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Kaladji A, Daoudal A, Duménil A, Göksu C, Cardon A, Clochard E, Lucas A, Lalys F. Predictive Models of Complications after Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2016; 40:19-27. [PMID: 27903486 DOI: 10.1016/j.avsg.2016.08.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 06/30/2016] [Accepted: 08/04/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND The risk of long-term complications after endovascular aneurysm repair (EVAR) is still higher than open surgery and is a critical issue. This study aims to make available reliable statistical predictive models of complications after EVAR. METHODS Two hundred and thirteen patients who underwent EVAR between 2002 and 2012 were included in this study. The preoperative computed tomography scans were analyzed with a dedicated workstation to provide spatially correct 3-dimensional data. Age, gender, operation-related factors, and 21 morphologic variables were measured and included in the analyses. Five postoperative outcomes were studied. After an initial selection of predictors based on univariate analysis, binomial logistic regression models were proposed for each outcome. The ability to predict each outcome was assessed with receiver operating characteristic curves considering that an area under the curve (AUC) > 0.70 is generally considered sufficiently accurate. RESULTS The mean age was 74.8 ± 8.6 years with a mean follow-up of 43.8 ± 22.1 months. Respectively, rates and risk factors of each outcome were 25.3% (n = 51) for abdominal aortic aneurysm (AAA) enlargement (age, number of patent sac branches, iliac calcifications and tortuosity, aneurysmal thrombus), 7% (n = 15) for type IA endoleak (neck calcification and AAA diameter), 3.7% (n = 8) for type IB endoleak (iliac tortuosity, AAA diameter, neck thrombus), 19.8% (n = 40) for type II endoleak (female, number of patent sac branches), and 25.9% (n = 55) for reintervention from any cause (neck calcification). The risk associated to each outcome can be calculated with a combination of these different preoperative variables. AUC for each outcome were 79.6% for AAA enlargement, 70.4% for reintervention, 81.3% for type IA endoleak, 92.3% for type IB endoleak, 70.6% for type II endoleak. CONCLUSIONS This study shows that an exhaustive description of the preoperative anatomy before EVAR is a powerful and reliable tool to predict the risk of developing the most common complications after EVAR.
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Affiliation(s)
- Adrien Kaladji
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France; INSERM, U1099, Rennes, France; University Rennes 1, Signal and Image Processing Laboratory (LTSI), Rennes, France.
| | - Anne Daoudal
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France; INSERM, U1099, Rennes, France; University Rennes 1, Signal and Image Processing Laboratory (LTSI), Rennes, France
| | - Aurélien Duménil
- INSERM, U1099, Rennes, France; University Rennes 1, Signal and Image Processing Laboratory (LTSI), Rennes, France
| | | | - Alain Cardon
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France
| | - Elodie Clochard
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France
| | - Antoine Lucas
- CHU Rennes, Department of Cardiothoracic and Vascular Surgery, Rennes, France; INSERM, U1099, Rennes, France; University Rennes 1, Signal and Image Processing Laboratory (LTSI), Rennes, France
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