Editor's Choice - Meta-Analysis of Compliance with Endovascular Aneurysm Repair Surveillance: The EVAR Surveillance Paradox

George A Antoniou; Nikolaos Kontopodis; Steven K Rogers; Jonathan Golledge; Thomas L Forbes; Francesco Torella; Hence J M Verhagen; Marc L Schermerhorn; International RIsk Stratification in EVAR (IRIS-EVAR) working group

doi:10.1016/j.ejvs.2022.10.033

Editor's Choice - Meta-Analysis of Compliance with Endovascular Aneurysm Repair Surveillance: The EVAR Surveillance Paradox

Eur J Vasc Endovasc Surg. 2023 Feb;65(2):244-254. doi: 10.1016/j.ejvs.2022.10.033. Epub 2022 Oct 20.

Authors

George A Antoniou¹, Nikolaos Kontopodis², Steven K Rogers³, Jonathan Golledge⁴, Thomas L Forbes⁵, Francesco Torella⁶, Hence J M Verhagen⁷, Marc L Schermerhorn⁸; International RIsk Stratification in EVAR (IRIS-EVAR) working group

Affiliations

¹ Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK. Electronic address: georgios.antoniou@manchester.ac.uk.
² Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University General Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Greece.
³ Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
⁴ Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia; Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia.
⁵ Division of Vascular Surgery, Peter Munk Cardiac Centre and University Health Network, University of Toronto, Toronto, Ontario, Canada.
⁶ Liverpool Vascular & Endovascular Service, Liverpool, UK; School of Physical Sciences, University of Liverpool, Liverpool, UK; Liverpool Centre for Cardiovascular Science, Liverpool, UK.
⁷ Division of Vascular and Endovascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.
⁸ Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA.

PMID: 36273676
DOI: 10.1016/j.ejvs.2022.10.033

Abstract

Objective: To compare the survival of patients who attended surveillance after endovascular aneurysm repair (EVAR) with those who were non-compliant.

Data sources: MEDLINE and Embase were searched using the Ovid interface.

Review methods: A systematic review was conducted complying with the PRISMA guidelines. Eligible studies compared survival in EVAR surveillance compliant patients with non-compliant patients. Non-compliance was defined as failure to attend at least one post-EVAR follow up. The risk of bias was assessed with the Newcastle-Ottawa scale, and the certainty of evidence using the GRADE framework. Primary outcomes were survival and aneurysm related death. Effect measures were the hazard ratio (HR) or odds ratio (OR) and 95% confidence interval (CI) calculated using the inverse variance or Mantel-Haenszel statistical method and random effects models.

Results: Thirteen cohort studies with a total of 22 762 patients were included. Eight studies were deemed high risk of bias. The pooled proportion of patients who were non-compliant with EVAR surveillance was 43% (95% CI 36 - 51). No statistically significant difference was found in the hazard of all cause mortality (HR 1.04, 95% CI 0.61 - 1.77), aneurysm related mortality (HR 1.80, 95% CI 0.85-3.80), or secondary intervention (HR 0.66, 95% CI 0.31 - 1.41) between patients who had incomplete and complete follow up after EVAR. The odds of aneurysm rupture were lower in non-compliant patients (OR 0.63, 95% CI 0.39 - 1.01). The certainty of evidence was very low for all outcomes. Subgroup analysis for patients who had no surveillance vs. those with complete surveillance showed no significant difference in all cause mortality (HR 1.10, 95% CI 0.43 - 2.80).

Conclusion: Patients who were non-compliant with EVAR surveillance had similar survival to those who were compliant. These findings question the value of intense surveillance in all patients post-EVAR and highlight the need for further research on individualised or risk adjusted surveillance.

Keywords: Abdominal aortic aneurysm; EVAR; Endovascular aneurysm repair; Follow up; Surveillance.

Publication types

Review