Long-term Impact of Sac Behavior at 12 Months After Elective Endovascular Aneurysm Repair on Survival, Endoleaks, and Reintervention

Abstract

Failure of the sac to regress at 12 months after endovascular aneurysm repair (EVAR) was reported to be associated with higher long-term mortality independent of reinterventions or endoleaks in a large Vascular Quality Initiative database. We reviewed our single-center closely monitored cohort of patients after elective EVAR to see whether sac behavior at 12 months affects survival, reintervention, and endoleak-free survival. All patients undergoing EVAR (15 fenestrated EVARs) between 2001 and 2018 with an imaging study at 1 year postoperatively (±6 months) were included. Those with sac diameter decrease ≥5 mm (group I, n = 238) were compared with those who remained stable (group II, n = 151) or increased (group III, n = 14). Of 449 patients, 403 were included (26 died within 6 months, 20 did not have follow-up computed tomography). Group I patients were younger (70.5 ± 7.2 years vs 72.8 ± 9.0 years vs 79.4 ± 9.1 years; P < .01). Group III had less hyperlipidemia (85% vs 81% vs 57%; P = .021). Mean diameter was 5.8 ± 0.9 cm, 5.8 ± 1.0 cm, and 6.0 ± 1.4 cm (P = NS). Follow-up was 65.6 ± 39.5 months clinically, 53 ± 37.3 months for last imaging. Overall survival (5 years: 76% ± 3% vs 64% ± 4% vs 71% ± 12%; P = .116; Fig) was similar, but aneurysm-related mortality-free survival was significantly less in group III but similar in groups I and II (5 years: 100%, 99% ± 0.1%, 92% ± 8%; P = .002). One patient each from group II and group III had aneurysm-related mortality. Endoleak-free survival (5 years: 93% ± 2% vs 72% ± 4% vs 7% ± 7%; P < .001) and reintervention-free survival (94% ± 2% vs 76% ± 4% vs 16% ± 10%; P < .001) were significantly different between groups. During follow-up, 4.2% in group I had sac increase. In group II, 29.8% had sac size decrease, 58.3% remained stable, and 11.9% had sac size increase, half of which decreased again after reinterventions. Last mean sac diameters were 4.2 ± 1.3 cm vs 5.5 ± 1.3 cm vs 7.5 ± 2.5 cm; P < .001). In closely monitored patients, failure of sac diameter decrease at 12 months is not associated with survival but is associated with new endoleaks and reinterventions. Patients with stable sacs should probably be more closely monitored as the endoleak and reintervention rate is significantly higher than for those with sac size decrease.