Compliance of postendovascular aortic aneurysm repair imaging surveillance

Social Determinants of Health Factors and Loss-To-Follow-Up in the Field of Vascular Surgery

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.

Exploring how military culture shapes veterans' perception of aortic aneurysm repair: A qualitative study

BACKGROUND

Veterans represent a distinct cultural group whose perceptions of illness and treatment are influenced by military culture. The study explores how prior military service shapes Veterans' assumptions and behaviors in the setting of aneurysm repair surgery.

STUDY DESIGN

We conducted content and thematic analysis of a case series of 10 transcripts from telephone interviews with older (76.7 ± 4.3 years) African American and White male Veterans now residing in the Southern U.S. who underwent open or endovascular aneurysm surgery at Veterans Affairs Medical Centers or university affiliates between 2004 and2019.

RESULTS

Throughout the continuum of care, Veterans described deferring to authority and not questioning provider's decisions ["I just can't make a judgment on that, because I'm not a doctor"]. Veterans valued commitment and articulated pride in keeping logistically challenging surveillance appointments [I always took them very seriously. . . If I'm scheduled for something by the doctor, I always make it."]. The routine structure of VA care aligned with Veterans military experiences, facilitating compliance with doctor's orders. However, procedural deviations in VA care were disconcerting for patients ["They haven't reached out to me in at least three years, since my surgery; I was being seen once a year and then all of a sudden, they just quit."]. While Veterans praised VA care, they exhibited sensitivity to signs of untoward treatment from clinical and support staff "…my surgeon, he never talked to me before, nor after, no anytime…I thought that maybe that wasn't right".

CONCLUSIONS

Military culture embodies rank, order, and respect, and remains a source of strength and stability for Veterans in their medical care late in life. Cultural competency about how military service has shaped Veterans' expectations can enhance providers' awareness of patients' military mindsets and inform surgeons' efforts to engage Veterans in shared decision making.

Duplex Scans Performed Immediately Following Lower Extremity Angioplasty and Stenting are of Limited Utility

BACKGROUND

Together with clinical examination, surveillance duplex examination represents the Society of Vascular Surgery recommendations for follow-up after endovascular intervention on the superficial femoral artery (SFA) and popliteal arterial segments. Compliance with postprocedural follow-up remains challenging. To establish a postangioplasty physiologic baseline, our institution began obtaining immediate postprocedural surveillance studies following lower extremity arterial interventions. We reviewed the utility of immediate postprocedural surveillance to determine if these studies enhanced postoperative care.

METHODS

Serial patients undergoing SFA and popliteal angioplasty and stenting from January 2014 to December 2020 were identified from our prospectively maintained Vascular Surgery database. Patient demographic information, procedural details, and procedural outcomes were subsequently analyzed from the electronic medical record.

RESULTS

Two hundred and sixty-three patients underwent 385 SFA and/or popliteal angioplasty/stenting interventions. Mean patient age was 64.8 ± 10 years. Among these 385 procedures, 350 (90.9%) were followed by immediate (<4 hours) postprocedural lower extremity arterial duplex scans. These 350 procedures included percutaneous transluminal angioplasty and/or stenting of the SFA (n = 236), popliteal artery (n = 34), or both (n = 80). Of these studies, 25 results (7.1%) were abnormal. One asymptomatic patient was admitted to hospital for immediate thrombolysis; however, the remaining 24 patients were followed clinically with no immediate intervention required. Abnormal results included 13 abnormalities appreciated on the final angiogram with 9 patients with known occlusions or stenoses, and 4 patients with mild to moderate CFA stenosis. Abnormal findings not detected on the final angiogram included 7 patients with mild to moderate stenosis and 5 patients with short occlusions (1.4%). All 5 patients with short segmental occlusions not detected on final arteriogram had preprocedural anatomy classified as either TASC C (TransAtlantic Inter-Society Consensus: SFA occlusions > 15 cm in length, n = 1) or TASC D (SFA occlusions > 20 cm in lenth, n = 4).

CONCLUSIONS

Immediate postprocedural duplex scans demonstrate significant vessel stenosis or occlusion in approximately 7% of cases but most stenoses and occlusions were noted on final arteriography. Duplex detected short segmental occlusions not noted on final arteriography were rare (1.4%), and occurred among patients with TASC C or TASC D occlusive disease. These duplex detected abnormalities rarely changed the patient's immediate plan of care. The performance of these immediate postprocedural duplex scans demonstrated limited clinical utility.

Influence of Home Location on Follow-Up Compliance after Endovascular Treatment for Abdominal Aortic Aneurysm

BACKGROUND

The complications of EVAR require compliance to a close follow-up imaging. The purpose of this study was to determine whether home location predicted a poor compliance to imaging follow-up after EVAR.

METHODS

We analyzed a cohort of patients treated by EVAR at the Besançon University Hospital between 2007 and 2017. Follow-up imaging followed the French High Health Authority recommendations. Noncompliance with follow-up compliance was defined as a first missed postoperative appointment or 2 consecutive missed appointments after the first control CT-scan, and 2 groups of patients were identified: compliant (group C) or noncompliant (group NC). Univariate and multivariate analyzes were used to investigate compliance risk factors. Collected complications included endoleaks, limb thrombosis, infections, and secondary ruptures.

RESULTS

Two hundred and fifty-eight of the 359 patients treated during this period were enrolled, including 233 men (90.3%), with a mean age of 74.0 years (±9.0) and a mean follow-up of 5.0 years (±2.6). The compliance rate was 38.8% and the 1-year mortality rate was 12.0%. Using univariate and multivariate analysis, a place of residence greater located over 60 min away from the hospital had a poor effect on compliance (Odd ratio [OR] = 0.58; P = 0.047). Peripheral arterial occlusive disease (PAD) and an abdominal aortic aneurysm (AAA) diameter greater than 5.0 cm were protective factors (OR = 2.23; P = 0.006 and OR = 1.85, respectively; P = 0.002). Four-year all-cause mortality was 21.0% in group C and 17.0% in the NC group (P = 0.54). Complications were more significant in group C (59.0%) compared to group NC (39.0%) (P = 0.001). Two ruptures occurred in the NC group (1.3%), versus none in the C group (P = 0.25).

CONCLUSIONS

In this study, a long distance from the home to the hospital was a detrimental factor for follow up compliance. However, a good compliance did not decrease the 4-year mortality rate. The high rate of noncompliance found should lead to a more personalized follow-up strategy taking into account the anatomical elements but also the comorbidities and some social aspects.

Cost of Follow Up After Endovascular Abdominal Aortic Aneurysm Repair in Patients With an Initial Post-Operative Computed Tomography Angiogram Without Abnormalities

OBJECTIVE

The Observing a Decade of Yearly Standardised Surveillance in EVAR patients with Ultrasound or CT Scan (ODYSSEUS) study was conducted to assess differences in outcomes of patients with continued or discontinued yearly follow up after endovascular abdominal aortic aneurysm repair (EVAR). Earlier results of this study showed that discontinued follow up was not associated with poor outcomes. Therefore, an incremental cost analysis and budget impact analysis of de-implementation of yearly imaging following EVAR was performed.

METHODS

In total, 1 596 patients from the ODYSSEUS study were included. The expected cost savings were assessed if yearly imaging was reduced in patients with a post-operative computed tomography angiogram without abnormalities made around 30 days after EVAR. Costs were derived from the Dutch costs manual, benchmark cost prices, and literature review. Costs were expressed in euros (€) and displayed at 2019 prices. Sensitivity analysis was performed by varying costs.

RESULTS

A difference of 24% in cost was found between patients with continued and discontinued imaging follow up. The cost per patient was €1 935 in the continued group vs. €1 603 per patient in the discontinued group at five years post-EVAR, with a mean difference of €332 (95% bias corrected and accelerated bootstrap confidence interval -741 to 114). De-implementation of yearly imaging would result in an annual nationwide cost saving of €678 471. Sensitivity analysis with variation in adherence rates, imaging, or secondary intervention costs resulted in a saving of at least €271 388 per year.

CONCLUSION

This study provided an in depth analysis of hospital costs for post-EVAR patients in the Netherlands with a modest impact on the Dutch healthcare budget.

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

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.

Longer follow-up intervals following EVAR are safe and appropriate after marked aneurysm sac regression

BACKGROUND

Abdominal aortic aneurysm (AAA) shrinkage after endovascular aortic aneurysm repair (EVAR) is a surrogate marker for successful exclusion. Our study characterized aneurysm sac remodeling after EVAR to identify a pattern that may be associated with benign AAA behavior and would safely allow a less rigorous follow-up regimen after EVAR.

METHODS

Elective infrarenal EVARs performed between 2008 and 2011 at our institution were retrospectively reviewed. AAA sac diameters using the minor axis measurement from ultrasound imaging or computer tomography angiogram imaging were compared with the baseline diameter from the 1-month postoperative computer tomography angiogram. The primary outcome was a composite of freedom from postoperative reintervention or rupture. We compared those with AAA sacs who regressed to predefined minimum diameter thresholds with those who did not. Outcomes were plotted with Kaplan-Meier curves and compared using log-rank testing and Fine-Gray regression using death as a competing risk, clustered on graft type. For patients whose AAA reached the minimum sac diameter, landmark analysis evaluated ongoing size changes including further regression and sac re-expansion.

RESULTS

A total of 540 patients (aged 75.1 ± 8.2 years; 82.0% male) underwent EVAR with an average preoperative AAA size of 55.2 ± 11.5 mm. The median postoperative follow-up was 5.3 years (interquartile range, 1.4-8.7 years) during which 64 patients underwent reintervention and 4 ruptured. AAA sac regression to ≤40 mm in diameter was associated with improved freedom from reintervention or rupture overall (log-rank, P < .01), which was maintained after controlling for the competing risk of death (P < .01). In 376 patients (70%) whose aneurysm sac remained >40 mm, 99 reinterventions were performed on 63 patients. Of 166 (31%) patients whose sac regressed to ≤40 mm, only 1 patient required a reintervention, and no one ruptured. The mean time to a diameter of ≤40 mm was 2.3 ± 1.9 years. Only eight patients (5%) developed sac re-expansion to >45 mm; all but two occurred at least 3 years after initially regressing to ≤40 mm.

CONCLUSIONS

In long-term follow-up, patients whose minimum AAA sac diameter regressed ≤40 mm after EVAR experienced a very low rate of reintervention, rupture, or sac re-expansion. Most sac re-expansion occurred at least 3 years after reaching this threshold and did not result in clinical events. Increasing follow-up frequency up to 3-year intervals once the AAA sac regresses to 40 mm would carry minimal risk of aneurysm-related morbidity.

Initial Post-Operative Visit Absenteeism is Associated with Worse Amputation-Free Survival after Tibial Angioplasty

OBJECTIVES

Tibial revascularization is often performed in the setting of critical limb ischemia and tissue loss requiring close patient monitoring in the early post-operative period for worsening gangrene and/or ischemia. Multiple studies have shown loss to follow-up (LTF) is an independent risk factor for poor outcomes in several vascular procedures. Therefore, we evaluated the risk factors relating to LTF against outcomes in patients undergoing tibial endovascular procedures with the hypothesis that poor post-operative visit compliance is associated with decreased amputation-free survival rates.

METHODS

We performed a single-institution retrospective chart review of patients who underwent therapeutic endovascular tibial revascularization between 2014-2018. Patient follow-up and outcomes of death or major amputation (trans-tibial/trans-femoral) were followed up to 36-months post-operatively. Patients who had undergone previous infra-geniculate interventions or reached mortality/major amputation within 30-days post-operatively were excluded from analysis.

RESULTS

We identified 89 patients who met inclusion criteria. The overall rate of attendance at less than <1 month, 1-6 months, 6-15 months and 15-36 months post-operatively were 60%, 64%, 60 and 40% respectively. 16% of patients had complete loss to follow-up. Patients without tissue loss (≤ Rutherford 4) were less likely to attend early <1 month and 1-6 month follow-up intervals. Notably, absenteeism from the first immediate post-operative visit was a significant risk factor for further absenteeism at 1-6 months (51% vs 26%; p=.01) and at greater than 6 month follow-up (48% vs 31%; p=.05). Compared to the cohort of all patients, failure to follow-up within 1 month was associated with a decrease in attendance from 64% to 26% at 1-6 months and 63% to 31% at more than 6 months. Missing the first post-operative visit was also associated with decreased amputation-free survival (p=.04).

CONCLUSIONS

Absenteeism from the first post-operative visit is associated with worse amputation-free survival and a significant risk factor for further absenteeism from post-operative care. Given these results, ensuring close immediate post-operative follow up is essential to improving outcomes in patients undergoing tibial revascularization.

Editor's Choice - Detection of Late Complications After Endovascular Abdominal Aortic Aneurysm Repair and Implications for Follow up Based on Retrospective Assessment of a Two Centre Cohort

OBJECTIVE

Endovascular aortic aneurysm repair (EVAR) is associated with the risk of late complications and mandates follow up. This retrospective study assessed post-EVAR complications in a two centre cohort. The study evaluated the rate of complications presenting with symptoms vs. those detected by imaging follow up. Additionally, the agreement between DUS and CTA in detecting complications was assessed in patients with both.

METHODS

All EVAR patients from 1998 to 2012 in two centres were included. Complications were classified based on whether they were symptomatic or detected by imaging, as well as based on imaging detection modality (DUS or CTA). For patients who had undergone DUS and CTA within three months of each other, the kappa coefficient of agreement was assessed.

RESULTS

Four hundred and fifty-four patients treated by EVAR were identified. The median follow up time was 5.2 (IQR 2.8-7.6) years. One hundred and eighteen patients (26%) developed 176 complications. One hundred and six (60.2%) of the complications were asymptomatic, and 70 (39.8%) were symptomatic. Two hundred and fifty-three patients had imaging with both modalities within three months of each other; the kappa coefficient for agreement between CTA and DUS for detecting clinically significant complications was 0.91. Regarding CTA as the standard modality, DUS had a sensitivity of 88.8% (95% CI 77.3-95.8%) and a specificity of 99.4% (95% CI 97.1-99.9%). Three of the complications missed by DUS were related to loss of proximal and distal seal, all occurring in patients with short sealing length on first post-operative CT scan.

CONCLUSION

Approximately a quarter of the patients developed complications, the majority of which were asymptomatic, underlining the importance of adequate surveillance. There was good agreement between CTA and DUS in detecting complications. Clinically significant complications related to inadequate seal were missed by DUS, suggesting that CTA still plays an important role in EVAR surveillance.

Discharge to a Post-Acute Care Facility after Emergent Femoral Artery Repair is Not Protective Against Wound Complications

BACKGROUND

Access site complication is the most common adverse event after endovascular intervention, and when emergent operative repair of the common femoral artery (CFA) is needed, patient morbidity can be significantly increased. The intent of this project was to identify predictors of wound events after emergent operative repair of the CFA due to an access site complication. It was hypothesized that patients discharged to a facility would benefit from an ongoing relationship with healthcare professionals as evidenced by more consistent follow-up and lower wound complication rates.

METHODS

Patients who had a percutaneous CFA access complication and required emergent open CFA repair at an academic medical institution between 2015 and 2018 were included, and the charts were reviewed retrospectively. Primary outcomes included wound complication and outpatient compliance with vascular surgery clinic visit. Dichotomous groups were evaluated by the chi-squared test, and continuous variables were evaluated by Student's t-test. Univariate and multivariate regression analyses were completed to assess risk factors contributing to wound event or failure of clinic follow-up.

RESULTS

Forty-four patients were identified with emergent CFA repair due to an access complication between July 2015 and June 2018. Among this population, 33% of patients had wound complications and 27% were discharged to a facility. Among those discharged to a facility, the rate of follow-up to the vascular surgeon's clinic was significantly lower than those discharged to home (40% vs. 85%, P < 0.05), and the incidence of wound complications appeared greater but did not reach statistical significance (50% vs. 27%, P = 0.11). Univariate analysis indicated that kidney disease, albumin <3 g/dL, and current smoking were predictive of wound complication, whereas on multivariate analysis, only kidney disease remained predictive (P < 0.05, odds ratio = 22). The modified frailty index (mFI) was not predictive of wound complications or compliance with follow-up. However, mFI did approach statistical significance when predicting discharge to a facility.

CONCLUSIONS

Despite the availability of medical personnel to arrange transportation and provide wound care in post-acute care facilities, patients who were discharged to a facility after CFA injury requiring emergent repair experienced lower compliance with clinic follow-up and may have suffered more wound complications. Strategies to improve compliance with patient follow-up and wound healing in patients sent to post-acute care facilities are warranted.

Effect of Imaging Surveillance After Endovascular Aneurysm Repair on Reinterventions and Mortality: A Systematic Review and Meta-analysis

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.

Importance of Follow-up Imaging in the Detection of Delayed Type 2 Endoleaks Despite Complete Aneurysmal Sac Shrinkage

Type 2 endoleaks usually constitute a benign and self-limited phenomenon, which rarely leads to aneurysmal sac expansion. However, in a small subset of patients, a persistent type 2 endoleak might pressurise the aneurysmal sac causing expansion. The authors present two cases with delayed new-onset type 2 endoleak. One occurred after standard endovascular aortic repair and the other after chimney endovascular aortic repair, causing expansion of the aneurysmal sac after a period of complete aneurysmal sac shrinkage. Accordingly, there is a risk of sac re-expansion due to delayed onset endoleaks, independent of the technique, justifying the need for a continuous follow-up despite long-term aneurysmal sac shrinkage.

Patient satisfaction and chronic illness are predictors of postendovascular aneurysm repair surveillance compliance

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.

Combined Type III and Type II Endoleaks after Endovascular Aneurysm Repair: Presentation of 2 Cases and a Literature Review

Although endovascular aneurysm repair is a feasible option for high-risk patients resulting in lower perioperative mortality when compared with open repair, the need for reintervention and long-term follow-up affects its use. The aim of the current report is to present 2 cases of patients with type IIIa endoleak from limb disconnection (one patient with double-bilateral endoleak) combined with a late type II endoleak and symptomatic sac growth treated in our department. We also performed a literature review about type III endoleaks and their treatment options.

Editor's Choice - The Implications of Non-compliance to Endovascular Aneurysm Repair Surveillance: A Systematic Review and Meta-analysis

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.

A Dedicated Surveillance Program Improves Compliance with Endovascular Aortic Aneurysm Repair Follow-up

BACKGROUND

Current recommendations suggest lifetime follow-up for endovascular aortic aneurysm repair (EVAR) patients to avoid consequences associated with endoleak and aneurysm enlargement. Follow-up compliance has been reported between 43% and 92%, with most single-center studies citing successful follow-up surveillance at less than 60%. We investigated follow-up completeness with a defined surveillance program and subsequent secondary intervention prevalence from a single center.

METHODS

Our surveillance program notified patients of the need for follow-up imaging and surgeon review. Data were obtained from retrospective review of a prospective database, including operative and follow-up details, follow-up imaging completeness, endoleak incidence, and secondary intervention prevalence.

RESULTS

Five hundred seventeen patients received elective EVAR from 2005 to 2015. Surveillance was achieved in 425 (82.3%). Mean number of follow-up studies was 4.2 ± 2.9 and median time to first follow-up was 36 days. Four hundred forty-eight patients (86.7%) had freedom from intervention. Sixty-nine unique patients (13.3%) had 107 secondary interventions. Median time to first secondary intervention in 69 patients was 476 days. Mean number of imaging studies for secondary intervention patients was 6.1 ± 3.9, compared with mean 3.4 ± 2.3 for patients without (P < 0.001). Overall mortality was 24.6% (n = 127), including 32 deaths of unknown cause (6.2% overall) and 95 of non-EVAR-related causes (18.3%). No aneurysm-related deaths were reported.

CONCLUSIONS

Regular post-EVAR surveillance through a dedicated program resulted in a high rate of follow-up compliance, 13.3% rate of secondary intervention, and low aneurysm-related mortality. Careful lifetime surveillance remains important in long-term care following elective EVAR.

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients

OBJECTIVES

To evaluate outcomes after endovascular treatment of patients with aneurysmal or occlusive vasculopathy in HIV-infected patients.

METHODS

Retrospective analysis of a prospective database of treatment outcomes in patients with HIV related vasculopathies between April 2005 and September 2015.

RESULTS

Sixty HIV patients presented with post-traumatic pseudoaneurysm formation (n = 7), aneurysmal disease (n = 24) or occlusive disease (n = 29 (48%)). The majority were male (42/60 (70%)), with a mean age of 43.9 years (SD ± 12.6). All seven patients with a post-traumatic pseudoaneurysm were treated by insertion of a covered stent (n = 6) or coiling (n = 1). All were successfully treated at 30 days, but only one patient returned for late surveillance. 23/24 patients who underwent insertion of a stent graft/covered stent for aneurysmal disease returned for 30 day review (one asymptomatic stent graft occlusion). Only 11 patients attended for late surveillance; 9/11 were asymptomatic with patent stent grafts. Late stent occlusion occurred in two (no further action (n = 1), major limb amputation (n = 1). In the 29 patients who underwent endovascular treatment for occlusive disease, 9 (31%) had immediate treatment failure (including 8 amputations (28%)). Of the sixteen who returned for serial review, 8 (50%) suffered further complications including 4 amputations. Overall, 12/29 treated patients (41%) ultimately underwent amputation.

CONCLUSIONS

In the immediate short term, an 'endovascular first' strategy was associated with good outcomes in HIV patients with aneurysmal disease. By contrast, outcomes were poor in HIV patients with occlusive disease. Whether this relates to the underlying natural history of HIV occlusive vasculopathies remains unclear. One major problem in trying to formulate meaningful management strategies is a generalised reluctance for HIV patients to return for surveillance.