Invited commentary

Abstract

This study by Hicks et al interrogated the Vascular Quality Initiative database to examine the effect of being lost to follow-up (LTF) on survival after endovascular aneurysm repair (EVAR). Medicare data had suggested that a lack of imaging after EVAR did not confer a survival disadvantage.1Garg T. Baker L.C. Mell M.W. Postoperative surveillance and long-term outcomes after endovascular aneurysm repair among Medicare beneficiaries.JAMA Surg. 2015; 150: 957-963Crossref PubMed Scopus (51) Google Scholar In the Vascular Quality Initiative EVAR population, only 49.9% of elective patients had a follow-up visit recorded in the database (an astonishing low number). Of this group, ∼11% each had phone follow-up or were LTF. The LTF group was older, had more comorbid conditions, and had larger aneurysms. The LTF group (and the phone follow-up group) had significantly lower survival compared with those with in-person follow-up. A coarsened exact matching on 30 preoperative and perioperative variables demonstrated that those LTF still had reduced survival (vs in person follow-up), although the differences compared with the multivariate analysis with in-person follow-up, were considerably smaller. Phone follow-up patients had fewer imaging studies, and survival outcomes were equivalent to the LTF group. The authors conclude that EVAR patients with more comorbidities and a higher incidence of in-hospital complications tend to be more frequently LTF and ultimately have worse survival outcomes. This study's conclusions differ from a study of EVAR Medicare patients that used a propensity-matched study design.1Garg T. Baker L.C. Mell M.W. Postoperative surveillance and long-term outcomes after endovascular aneurysm repair among Medicare beneficiaries.JAMA Surg. 2015; 150: 957-963Crossref PubMed Scopus (51) Google Scholar The patients with incomplete postoperative EVAR surveillance had few ruptured abdominal aortic aneurysms postoperatively, fewer reinterventions, and no reduction in aneurysm-related survival. Nonadherence to Society for Vascular Surgery suggested guidelines for postoperative EVAR was surprisingly not associated with poorer outcomes. Other population-derived data published suggest that regular imaging after EVAR is associated with reduced mortality that becomes more pronounced as the length of follow-up increases.2de Mestral C. Croxford R. Roche-Nagle G. PC036. Ten years of endovascular aortic aneurysm repair: a population-based evaluation of postoperative imaging and mortality [Abstract].J Vasc Surg. 2016; 6: 163S-164SAbstract Full Text Full Text PDF Google Scholar All of these data demonstrate a failure to achieve the Society for Vascular Surgery EVAR follow-up guidelines. The preponderance of data, in my opinion, demonstrates those who are LTF have worse long-term outcomes and mortality than those with imaging and in-person follow-up. Key barriers to complete follow-up include patient factors (age, choice to come for follow-up, and comorbidities), provider factors (databases and coordinators dedicated to ensuring imaging and follow-up), and the lack of patient-specific follow-up guidelines that take into account the presence or absence of endoleaks at the first follow-up, anatomic considerations (short or angulated aortic necks or common iliac landing zones), sac shrinkage, and other factors. Database software dedicated to EVAR patient-specific follow-up should assist providers to improve follow-up compliance and determine whether this improves aneurysm-related mortality. Vascular surgeons need to ensure careful EVAR follow-up or risk compromising its promise of comparable outcomes to open repair.3Patel R. Sweeting M.J. Powell J.T. Greenhaugh R.M. EVAR trial investigatorsEndovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial.Lancet. 2016; 388: 2366-2374Abstract Full Text Full Text PDF PubMed Scopus (606) Google Scholar Endovascular aneurysm repair patients who are lost to follow-up have worse outcomesJournal of Vascular SurgeryVol. 65Issue 6PreviewSociety for Vascular Surgery practice guidelines recommend 1- and 12-month follow-up with computed tomography imaging for the year after endovascular aneurysm repair (EVAR). We describe the incidence, risk factors, and outcomes of EVAR patients who are lost to follow-up (LTF). Full-Text PDF Open Archive