In the abdominal aortic aneurysm (AAA) endovascular repair (EVAR) post-procedural management paradigm, optimal graft surveillance methods and intervals for individual patients remain poorly defined. Many post-EVAR AAA patients undergo what in retrospect prove to be unnecessary, expensive, and potentially morbid imaging studies, whereas others experience sometimes catastrophic device-related events between prescribed imaging intervals.
Although axiomatic in modern medical practice, the premise of this article—patients rigorously followed up will achieve better procedural outcome—is not fully justified by the data presented. The authors were not able to prove the primary study hypothesis, defined in the abstract, that late follow-up rates for EVAR in general practice are inferior to those reported in protocol-driven clinical trials, and no significant differences were noted in event rates for protocol or nonprotocol patients, despite the fact that protocol patients had longer mean follow-up.
The discussion highlights the potential importance of study nurse involvement in postoperative patient compliance, but no differences were noted between protocol and nonprotocol patients for adherence to their respective recommended follow-up. Patients in the “incomplete” category experienced more major late complications, but the numbers were small (n = 6 vs n = 1), and there is no direct evidence that “complete” compliance would have prevented these five additional events.
Although the authors’ experiences highlight several real world concerns related to postprocedural EVAR management, optimal outcome will likely depend on how rather than how often patients are followed up. The facts remain that:
1.the ideal surveillance interval for individual patients remains entirely arbitrary and almost certainly is dependent on device and patient specific issues,
2.the cost and risks associated with follow-up imaging based on computed tomography add significantly to the limitations of EVAR management as currently practiced, and
3.although the performance of EVAR does imply life long vigilance regarding AAA disease status, optimal care will ultimately derive from patient’s specific data (such as wall or sac tension) or as of yet to be identified biomarker(s) that may, in a cost-effective and ideally continuous fashion, directly reflect underlying disease status.
FULL TEXT