Any Postoperative Surveillance Improves Survival After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

Abstract

Endovascular aortic repair (EVAR) has become first-line therapy for ruptured abdominal aortic aneurysms (rAAA). Rigorous surveillance imaging after EVAR is recommended due to the high risk of endograft complications in this population. Follow-up compliance is known to be poor after elective EVAR but has not been studied in patients after EVAR for rAAA (rEVAR). Our objective is to investigate patient factors that predict incomplete surveillance and examine how compliance impacts outcomes after rEVAR. This was a retrospective observational study of patients undergoing rEVAR at a multiple hospital single health care center (2003-2020). Patients were excluded if they underwent open conversion during their index hospitalization or died within 60 days of surgery. Follow-up surveillance was broadly categorized as complete surveillance (1-month postoperative visit and annually thereafter) or incomplete surveillance, which comprised both patients completely lost to follow-up (LTF) and those with less than recommended postoperative surveillance (minimal compliance; MC). We investigated predictors of complete vs incomplete surveillance by multivariate logistic regression. Kaplan-Meier curves were generated for surveillance groups and compared using the log-rank test. Multivariate Cox regression was used to explore the effect of surveillance compliance on survival. One-hundred sixty patients (mean age: 74 ± 10.1 years, 81.2% male) out of 673 total rAAA met study inclusion criteria. The majority were white (96.5%) with a history of tobacco use (69.7%), hypertension (59.6%), and coronary artery disease (56.0%). Complete surveillance was seen in 41.3% of our cohort. The remainder had either MC (29.4%) or were LTF (29.4%). On multivariable regression, longer driving distance from home to treating hospital, male sex, and lack of a primary care provider (PCP) were associated with incomplete surveillance. Death occurred in 65 (40.6%) and reintervention in 25 (15.6%) patients during the study period. Survival was not different between complete and incomplete surveillance groups (P = .24). Subgroup analysis revealed a similar survival for patients with complete surveillance and those with minimal compliance. On multivariate Cox analysis, any follow-up conferred improved survival over LTF (hazard ratio, 0.57; 95% confidence interval, 0.331-0.997; P = .049) (Fig). Incomplete follow-up surveillance was observed in over 50% of patients who underwent rEVAR and was associated with longer driving distance, male sex, and lack of listed PCP. Any follow-up after rEVAR conferred a survival advantage. Thus, identification of patient level risk factors for poor follow-up before discharge will guide the design of mitigation strategies to prevent LTF.