Follow-up compliance in patients undergoing abdominal aortic aneurysm repair at Veterans Affairs hospitals.

OBJECTIVE: The Society for Vascular Surgery guidelines recommend annual imaging surveillance following endovascular aneurysm repair (EVAR) and every 5 years following open surgical repairs (OSR) of abdominal aortic aneurysms (AAAs). Adherence to these guidelines is low outside of clinical trials, and compliance at Veterans Affairs (VA) hospitals is not yet well-established. We examined imaging follow-up compliance and mortality rates after AAA repair at VA hospitals. METHODS: We queried the VA Surgical Quality Improvement Program database for elective infrarenal AAA repairs, EVAR and OSR, then merged in follow-up imaging and mortality information. Mortality rate over time was derived using Kaplan-Meier estimation. Generalized estimating equation with a logit link and a sandwich standard error estimate was performed to compare the probability of having annual follow-up imaging over time between procedure types and to identify variables associated with follow-up imaging for EVAR patients. RESULTS: Our analysis included 11,668 patients who underwent EVAR and 4507 patients who underwent OSR at VA hospitals between the years 2000 and 2019. The 30-day mortality rate for EVAR and OSR was 0.37% and 0.82%, respectively. OSR was associated with lower long-term mortality after adjusting age, sex, American Society of Anesthesiologists classification and preoperative renal failure with an adjusted hazard ratio of 0.88 (95% confidence interval, 0.84-0.92; P < .01). Of surviving patients, the follow-up imaging rate was 69.1% by 1 year post-EVAR. The follow-up rate after 5 years was 45.6% post-EVAR compared with 63.6% post-OSR of surviving patients. A history of smoking or drinking, baseline hypertension, and known cardiac disease were independently associated with poor follow-up after EVAR. CONCLUSIONS: Patients undergoing elective open AAA repair in the VA hospital system had lower long-term mortality compared with patients who underwent endovascular repair. Compliance with post-EVAR imaging is low. Patient factors associated with poor post-EVAR imaging surveillance were smoking within the last year, excess alcohol consumption, and cardiac risk factors including hypertension, prior myocardial infarction, and congestive heart failure.

Outcomes and Imaging Surveillance Adherence in Juxta-Renal Aortic Aneurysms Repairs: A VASQIP Retrospective Study.

OBJECTIVE: Fenestrated endovascular aortic repair (FEVAR) has demonstrated its value in the management of juxtarenal abdominal aortic aneurysms (JAAA), but data were largely derived from clinical trials and high-volume centers. Although routine imaging surveillance is recommended following endovascular interventions, little is known regarding follow-up compliance post-FEVAR. We examined the real-world treatment outcomes and adherence to the postoperative follow-up protocol after elective interventions for JAAA at Veteran Affairs (VA) health care facilities, the largest integrated health care system in the United State. METHODS: This is a retrospective cohort study. We queried the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database for elective FEVARs and juxtarenal open surgical repairs (j-OSR), then merged follow-up imaging and mortality information. Our primary endpoints were mortality following FEVAR and j-OSR, and adherence to surveillance guidelines. Secondary endpoints included short-term postoperative complications. RESULTS: A total of 1110 veterans who underwent first-time JAAA repair between 2002 and 2019 (FEVAR, 26% [n=290]; j-OSR, 74% [n=820]) were included in the analysis. The number of j-OSR captured in the database gradually declined by 50%, from 62 interventions in 2002 to 28 in 2019, while FEVAR procedures quadrupled from 20 procedures in 2014 to 94 in 2019. The median follow-up was 3.99 years (95% confidence interval [CI]: 3.73-4.87) for FEVAR patients, and 12.80 (12.31-13.70) for those that underwent jOSR. A significantly lower risk of 30-day mortality was observed following FEVAR compared to j-OSR (1% vs 5%, odds ratio [OR]: 5.03 [1.54-16.38]; p=0.003). At 5 years, FEVAR was linked with significantly higher mortality (41.5% vs 21%, p<0.001) after adjusting for confounders (aHR=2.10 [1.56-2.82], p<0.001). Of surviving patients, the follow-up imaging rate was 66.3% by 1-year post-FEVAR. Follow-up rate at 5 years was 7% post-FEVAR compared to 32% post j-OSR. CONCLUSION: Elective FEVAR is associated with lower perioperative mortality and morbidities compared to elective j-OSR for juxtarenal aortic aneurysms. However, the perioperative survival benefits of FEVAR diminish over time, with its mortality surpassing that of j-OSR at longer follow-up periods. The compliance with post-FEVAR imaging surveillance is also low. Further research is warranted to develop strategies to improve adherence to imaging surveillance protocols. CLINICAL IMPACT: This study provides real-world evidence on the outcomes and follow-up adherence following fenestrated endovascular aortic repair (FEVAR) for juxtarenal abdominal aortic aneurysms (JAAA) in the Veterans Affairs health care system. With FEVAR's increasing use, the findings highlight the need for improved surveillance protocols, as adherence to postoperative imaging declines significantly after the first year. Clinicians should be aware of the risk of long-term mortality despite FEVAR's short-term benefits, urging better follow-up strategies that relay a survival benefit for patients.