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Is EVAR Surveillance Necessary For The First Three Years Following An Initially Normal Duplex Post-Operative Study?
Douglas A. Troutman, DO, Mohammed Chaudry, MD, Matthew J. Dougherty, MD, Keith D. Calligaro, MD.
Pennsylvania Hospital, Philadelphia, PA, USA.
Objective: We have previously shown that duplex ultrasonography (DU) may replace computed tomographic angiogram (CT-A) as the primary surveillance tool for endovascular aortic aneurysm repair (EVAR). Current Society for Vascular Surgery practice guidelines suggest that if CT-A does not document endoleak, aneurysm sac enlargement, or limb stenosis at 1 and 12 months post-EVAR, surveillance studies may be performed annually. The purpose of this study is to determine whether the time to the second surveillance DU study can be safely postponed to 3 years post-EVAR if the initial study is normal.
Methods: Between 1998-2013, DU surveillance was performed in our accredited non-invasive vascular laboratory at 1 week, 6 months, and annually after 410 EVARs (follow-up: mean, 35 months; range, 1-151 months). DU measured sac diameter, intrasac endoleak peak systolic velocities (PSVs), and PSVs within the endograft limbs. If endoleak, limb stenosis/kinking, or increase in sac size was documented, DU surveillance was performed more frequently or CT-A and possible intervention were performed.
Results: Based on DU surveillance, 113 (27%) patients were diagnosed as having either endoleak [95 (23%) patients with 118 endoleaks: 15 (13%) Type I, 90 (76%) Type II, 11 (9%) Type III, 2 (2%) Type IV] or graft limb stenosis [18 (4%) patients, based on PSV >300 cm/s] during the follow-up period. Intervention was performed in 33% (37) of the 113 patients with endoleak or limb stenosis, or in 9% (37/410) of the total group, during the follow-up period of 1-151 months. Only 2.2% (7/325) of patients with an initial normal post-EVAR DU went on to develop endoleak or limb stenosis/kinking that required intervention during 3 year follow-up vs. 25% (21/85) of patients with an initial abnormal post-EVAR DU (p = 0.0001).
Conclusion: These findings suggest that follow-up DU surveillance can be postponed until 3 years post-EVAR if the initial surveillance DU is normal (no endoleak, sac enlargement, stenosis, or kinking) with minimal risk of an adverse clinical event.
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