Response to “Re ‘European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms’”

Abstract

Mr Antoniou's knowledgeable comments on risk stratification and surveillance algorithms for endovascular aneurysm repair (EVAR) are much appreciated.1Antoniou G.A. Risk stratification and surveillance algorithms for endovascular aneurysm repair.Eur J Vasc Endovasc Surg. 2020; (this issue)Abstract Full Text Full Text PDF Scopus (2) Google Scholar The value of prophylactic regular follow up imaging after EVAR is uncertain. Although the need for an early clinical and imaging follow up, to evaluate the success of the intervention, is not questioned, the previous routine, that everyone should have regular (often annual lifelong) follow up thereafter, has little support in the literature. Instead, a growing body of evidence suggests that a more individual approach may be reasonable. Consequently, the European Society for Vascular Surgery (ESVS) 2019 abdominal aortic aneurysm (AAA) guidelines2Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.Editor's choice – European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (943) Google Scholar issues a moderately strong recommendation (Class IIa) to perform early (within 30 days) post-operative follow up imaging, preferably with computed tomography angiography. However, for continuing surveillance, the ESVS gives a weak recommendation (Class IIb) to consider stratification to less frequent imaging follow up for patients considered at low risk of EVAR failure. As Antoniou points out, the risk of complications after EVAR is multifactorial, which is why risk stratification can be complex, and the optimal risk assessment has not yet been clarified. The ESVS 2019 AAA guidelines make no specific recommendations as to exactly how the risk stratification should be done, but points out some important aspects that might be considered: (1) the achieved seal; (2) the presence of an endoleak; and (3) sac dynamic on early follow up imaging. The ESVS guidelines provides an example of what a follow up algorithm based on such criteria might look like but does not provide specific recommendations.2Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.Editor's choice – European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (943) Google Scholar Mr Antoniou proposes an alternative risk stratification system, based on more variables and thus more complexity. In addition to post-operative imaging findings, pre-operative anatomical parameters, device related factors, and procedure performance are evaluated.1Antoniou G.A. Risk stratification and surveillance algorithms for endovascular aneurysm repair.Eur J Vasc Endovasc Surg. 2020; (this issue)Abstract Full Text Full Text PDF Scopus (2) Google Scholar Many of these variables interact with each other, and the question is which ones ultimately matter. It is unlikely that this issue will be clarified in randomised controlled trials, as power calculations show that several thousand patients need to be randomised and followed for a very long time (5–10 years), to be able to detect a clinically relevant difference between two strategies. Instead, we have to rely on prospective cohort and register studies to obtain the needed knowledge to further refine follow up routines after EVAR. Risk Stratification and Risk Specific Surveillance for Endovascular Aneurysm RepairEuropean Journal of Vascular and Endovascular SurgeryVol. 60Issue 6PreviewAlthough there is no evidence to suggest imaging surveillance is an essential part of follow up after endovascular aneurysm repair (EVAR), it is universally applied in the hope it will identify EVAR related complications before they become clinically manifested. In view of the intra- and international variability in surveillance strategies, the European Society for Vascular Surgery clinical practice guidelines proposed an EVAR follow up algorithm based on patient stratification.1 The proposed stratification arbitrarily considered three prognostic factors concerning the first post-operative examination, i.e., endoleak, inadequate seal, and absence of sac shrinkage defined as a reduction in aneurysm sac ≥ 10 mm. Full-Text PDF Open Archive