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Impact Of Imaging Surveillance Compliance On Outcomes After Endovascular Abdominal Aortic Aneurysm Repair In VA Hospitals
Laura Newton, MD1, Aravind Ponukumati, MD
1, Gabrielle Zwain, BA
1, Caroline Korves, MPH
1, Kayla Moore, BA
2, Shipra Arya, MD
3, Olamide Alabi, MD
4, Salvatore Scali, MD
5, Emily Spangler, MD
6, Philip Goodney, MD
1.
1White River Junction Veterans Affairs Medical Center, White River Junction, VT, USA,
2Dartmouth Health, Lebanon, NH, USA,
3Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA,
4Atlanta Veterans Affairs Healthcare System, Atlanta, GA, USA,
5Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, USA,
6Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
OBJECTIVES: To study the relationship between compliance with guideline-recommended annual imaging surveillance after endovascular aortic repair (EVAR) and long-term EVAR outcomes.
METHODS: Veterans who underwent EVAR between 1/1/2000-12/31/2023 in VA facilities were retrospectively examined. The exposure was imaging surveillance compliance, defined as at least one imaging study (CT, US, or MRI) per year after EVAR. The outcomes were all-cause mortality, reintervention, and late rupture. Both a landmark analysis and Cox proportional hazard modeling were performed. In the landmark analysis, surveillance compliance was assessed during the landmark period, defined as the first two post-EVAR years. Each patient’s compliance was categorized as none (no imaging obtained during landmark period), half (imaging obtained in one year), or full (imaging obtained both years). Kaplan-Meier survival curves were created to evaluate each outcome in the 10 years following the landmark period. This analysis was repeated using different landmark periods spanning years 0-9 post-EVAR and separately using a 3-year landmark period. For each year until 10 years post-EVAR, a Cox proportional hazard model was created in which imaging compliance the prior year was used to predict outcomes the following year. Models were adjusted for age, sex, race, VA priority group, and baseline Charlson Comorbidity Index.
RESULTS: There were 27,792 Veterans (mean age 71.7 years, 82.8% White, 99.4% male) who underwent EVAR during the study period. Within the first decade of surveillance, 45.3% of Veterans died, 21.1% had reinterventions, and 0.27% experienced late rupture. The landmark analysis found no significant differences in any outcomes of interest (survival (Figure 1), reintervention, or rupture) across the three compliance categories. This held true regardless of the landmark period’s start or size. In the adjusted Cox proportional hazard models, compliance was associated with reintervention (aHR 1.328; CI 1.220, 1.446), but not with death or rupture.
CONCLUSIONS: Patients with varying imaging surveillance compliance had no differences in long-term EVAR outcomes by landmark analysis. In Cox models, compliance is associated with reintervention but not with risk of rupture or death. These results may help inform a needed conversation reconsidering post-EVAR imaging surveillance recommendations once its utility in various clinical scenarios is better ascertained.
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