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

Abstract

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.

Commentary: Surveillance After EVAR: Still Room for Debate

“…One wonders then if these exams are performed simply to reassure the surgeon and/or the patient. Indeed, de Mik et al 3 found that only 7% of reinterventions were performed in the compliant group, which is far below the 20% rate mentioned in the EVAR-1 trial. 7 Furthermore, for the 7%, the proportion of reinterventions resulting from complications detected as a consequence of surveillance, as opposed to those resulting from declared symptoms, is not reported.…”

“…The conclusions of the study by de Mik et al, 3 more reintervention and no protection against mortality with surveillance, provide food for thought and invite us to revisit the concept of surveillance as it is proposed today. Should the protocol be simplified or replaced by a surveillance schedule tailored according to risk stratification?…”

“…In the August 2019 issue of the JEVT , de Mik and colleagues 3 present a systematic review and meta-analysis questioning the impact of surveillance compliance on reintervention and mortality. We know from the EVAR trials that the majority of deaths after abdominal aortic aneurysm repair occur from non-aortic causes (14.9% per 100 person-years vs 1.3%).…”

Management of Abdominal Aortic Aneurysm Disease: Similarities and Differences Among Cardiovascular Guidelines and NICE Guidance

“…53 The survival benefit for EVAR after 3 years appeared to be related to compliance. 54 A recent meta-analysis showed that patients who were compliant with imaging surveillance appeared to undergo more reinterventions than those who were partially or noncompliant. However, imaging surveillance did not seem to protect against mortality.…”

Postoperative surveillance and long-term outcome after endovascular aortic aneurysm repair in the Netherlands: study protocol for the retrospective ODYSSEUS study

“…This suggests that post-EVAR surveillance protocols provide no benefit to a large group of patients, as complications occur in between surveillance visits 8 9. Imaging surveillance may even lead to unnecessary interventions and it does not appear to be associated with improved survival 9 10. We hypothesise that the requirement for routine imaging for patients at low risk can be reduced.…”