ENDOVASCULAR ANEURISM REPAIR (EVAR) — CONSIDERATIONS ON CURRENT FOLLOW-UP STRATEGIES
Abdominal aortic aneurysm (AAA) is a cumbersome pathology, with catastrophic consequences when not properly diagnosed and treated. Nowadays, EVAR became an established treatment option for AAA, with better perioperative outcomes when compared to open surgery, and is quickly gaining a position of preference among the patients. However, the occurrence of endoleaks is described as the most common adverse event associated to EVAR. Consequently, we review the definition and classification of endoleaks as well as their potential risks and management. Nonetheless, according to the current follow-up protocols of ESVS, this technique requires an extensive imaging follow-up, usually by means of computed tomographic angiography (CTA), which carries increased economic cost and leads us to discuss related great radiation hazards. Concerning the latter, we also review the selected studies and we concluded that the first month CTA is the single most important imaging exam for patients’ prognosis and, once no complications are found, other reviewed imaging follow-up strategies should be undertaken to minimize radiation exposure and yet further risks for the patients. Therefore, this article establishes an overview about the current evidence and future strategies on EVAR imaging follow-up.
A comprehensive review. Exp Clin Cardiol 2011;16:11–5.
2. Pearce WH, Zarins CK, Bacharach JM, American Heart Association Writing
G. Atherosclerotic Peripheral Vascular Disease Symposium II: controversies
in abdominal aortic aneurysm repair. Circulation 2008;118:2860–3.
3. Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with
an abdominal aortic aneurysm: the Society for Vascular Surgery
practice guidelines. J Vasc Surg 2009;50:S2-49.
4. Assar AN, Zarins CK. Ruptured abdominal aortic aneurysm:
a surgical emergency with many clinical presentations. Postgrad
Med J 2009;85:268–73.
5. Brewster DC, Cronenwett JL, Hallett JW, Jr., et al. Guidelines for the
treatment of abdominal aortic aneurysms. Report of a subcommittee
of the Joint Council of the American Association for Vascular Surgery
and Society for Vascular Surgery. J Vasc Surg 2003;37:1106–17.
6. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing
conventional and endovascular repair of abdominal aortic aneurysms.
The New England journal of medicine 2004;351:1607–18.
7. United Kingdom ETI, Greenhalgh RM, Brown LC, et al. Endovascular
versus open repair of abdominal aortic aneurysm. The New England
journal of medicine 2010;362:1863–71.
8. Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following
endovascular vs open repair of abdominal aortic aneurysm:
a randomized trial. JAMA 2009;302:1535–42.
9. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open
or endovascular repair of abdominal aortic aneurysm. The New
England journal of medicine 2010;362:1881–9.
10. Lederle FA, Freischlag JA, Kyriakides TC, et al. Long-term comparison
of endovascular and open repair of abdominal aortic aneurysm.
The New England journal of medicine 2012;367:1988–97.
11. Patel R, Sweeting MJ, Powell JT, Greenhalgh RM. Endovascular versus
open repair of abdominal aortic aneurysm in 15-years' follow-up
of the UK endovascular aneurysm repair trial 1 (EVAR trial 1):
a randomised controlled trial. The Lancet 2016;388:2366–74.
12. Grima MJ, Boufi M, Law M, et al. Editor's Choice — The Implications
of Non-compliance to Endovascular Aneurysm Repair Surveillance:
A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg
13. Schurink GW, Aarts NJ, van Bockel JH. Endoleak after stent-graft
treatment of abdominal aortic aneurysm: a meta-analysis of clinical
studies. Br J Surg 1999;86:581–7.
14. Hobo R, Buth J, collaborators E. Secondary interventions following
endovascular abdominal aortic aneurysm repair using current endografts.
A EUROSTAR report. J Vasc Surg 2006;43:896–902.
15. Marrewijk Cv, Buth J, Harris PL, Norgren L, Nevelsteen A, Wyatt MG.
Significance of endoleaks after endovascular repair of abdominal
aortic aneurysms: The EUROSTAR experience. Journal of Vascular
16. Buth J, Laheij RJ. Early complications and endoleaks after endovascular
abdominal aortic aneurysm repair: report of a multicenter
study. J Vasc Surg 2000;31:134–46.
17. Baum RA, Stavropoulos SW, Fairman RM, Carpenter JP. Endoleaks
after Endovascular Repair of Abdominal Aortic Aneurysms.
Journal of Vascular and Interventional Radiology 2003;14:1111–7.
18. Silverberg D, Baril DT, Ellozy SH, et al. An 8-year experience with
type II endoleaks: natural history suggests selective intervention
is a safe approach. J Vasc Surg 2006;44:453–9.
19. Jones JE, Atkins MD, Brewster DC, et al. Persistent type 2 endoleak
after endovascular repair of abdominal aortic aneurysm is associated
with adverse late outcomes. J Vasc Surg 2007;46:1–8.
20. Maleux G, Poorteman L, Laenen A, et al. Incidence, etiology, and
management of type III endoleak after endovascular aortic repair.
J Vasc Surg 2017.
21. Chen J, Stavropoulos SW. Management of Endoleaks. Semin Intervent
22. Cornelissen SA, Verhagen HJ, Prokop M, Moll FL, Bartels LW.
Visualizing type IV endoleak using magnetic resonance imaging with
a blood pool contrast agent. J Vasc Surg 2008;47:861–4.
23. Oderich GS, Greenberg RK, Farber M, et al. Results of the United States
multicenter prospective study evaluating the Zenith fenestrated
endovascular graft for treatment of juxtarenal abdominal aortic
aneurysms. J Vasc Surg 2014;60:1420–8 e1-5.
24. Zhou W, Blay E, Jr., Varu V, et al. Outcome and clinical significance
of delayed endoleaks after endovascular aneurysm repair. J Vasc
25. Schlosser FJ, Gusberg RJ, Dardik A, et al. Aneurysm rupture after
EVAR: can the ultimate failure be predicted? Eur J Vasc Endovasc
26. Mehta M, Sternbach Y, Taggert JB, et al. Long-term outcomes
of secondary procedures after endovascular aneurysm repair.
J Vasc Surg 2010;52:1442–9.
27. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular
Surgery practice guidelines on the care of patients with an abdominal
aortic aneurysm. J Vasc Surg 2018;67:2–77 e2.
28. Patel A, Edwards R, Chandramohan S. Surveillance of patients
post-endovascular abdominal aortic aneurysm repair (EVAR).
A web-based survey of practice in the UK. Clin Radiol 2013;68:580–7.
29. Jones C, Badger SA, Boyd CS, Soong CV. The impact of radiation dose
exposure during endovascular aneurysm repair on patient safety.
J Vasc Surg 2010;52:298–302.
30. Kalef-Ezra JA, Karavasilis S, Ziogas D, Dristiliaris D, Michalis LK, Matsagas
M. Radiation burden of patients undergoing endovascular abdominal
aortic aneurysm repair. J Vasc Surg 2009;49:283–7; discussion 7.
31. Bannazadeh M, Altinel O, Kashyap VS, Sun Z, Clair D, Sarac TP.
Patterns of procedure-specific radiation exposure in the endovascular
era: impetus for further innovation. J Vasc Surg 2009;49:1520–4.
32. Motaganahalli R, Martin A, Feliciano B, Murphy MP, Slaven J,
Dalsing MC. Estimating the risk of solid organ malignancy in patients
undergoing routine computed tomography scans after endovascular
aneurysm repair. J Vasc Surg 2012;56:929–37.
33. Dias NV, Riva L, Ivancev K, Resch T, Sonesson B, Malina M. Is there
a benefit of frequent CT follow-up after EVAR? Eur J Vasc Endovasc
34. Garg T, Baker LC, Mell MW. Adherence to postoperative surveillance
guidelines after endovascular aortic aneurysm repair among
Medicare beneficiaries. J Vasc Surg 2015;61:23–7.
35. Powell J. RS02. Three-Year Outcomes of the IMPROVE Trial for Ruptured
Abdominal Aortic Aneurysm. Journal of Vascular Surgery 2017;65:46S.
36. Mills JL, Sr., Duong ST, Leon LR, Jr., et al. Comparison of the effects
of open and endovascular aortic aneurysm repair on long-term renal
function using chronic kidney disease staging based on glomerular
filtration rate. J Vasc Surg 2008;47:1141–9.
37. Kirkpatrick VE, Wilson SE, Williams RA, Gordon IL. Surveillance
computed tomographic arteriogram does not change management
before 3 years in patients who have a normal post-EVAR study.
Ann Vasc Surg 2014;28:831–6.
38. Patel MS, Carpenter JP. The value of the initial post-EVAR computed
tomography angiography scan in predicting future secondary procedures
using the Powerlink stent graft. J Vasc Surg 2010;52:1135–9.
39. Bastos Goncalves F, van de Luijtgaarden KM, Hoeks SE, et al. Adequate
seal and no endoleak on the first postoperative computed tomography
angiography as criteria for no additional imaging up to 5 years
after endovascular aneurysm repair. J Vasc Surg 2013;57:1503–11.
40. Sternbergh WC, 3rd, Greenberg RK, Chuter TA, Tonnessen BH, Zenith I.
Redefining postoperative surveillance after endovascular aneurysm
repair: recommendations based on 5-year follow-up in the US Zenith
multicenter trial. J Vasc Surg 2008;48:278–84; discussion 84–5.
41. Han SM, Patel K, Rowe VL, Perese S, Bond A, Weaver FA. Ultrasounddetermined
diameter measurements are more accurate than axial
computed tomography after endovascular aortic aneurysm repair.
J Vasc Surg 2010;51:1381–7; discussion 7–9.
42. Jawad N, Parker P, Lakshminarayan R. The role of contrast-enhanced
ultrasound imaging in the follow-up of patients post-endovascular
aneurysm repair. Ultrasound 2016;24:50–9.
43. Scaife M, Giannakopoulos T, Al-Khoury GE, Chaer RA, Avgerinos ED.
Contemporary Applications of Ultrasound in Abdominal Aortic
Aneurysm Management. Front Surg 2016;3:29.
44. Dias NV, Ivancev K, Malina M, et al. Direct intra-aneurysm sac pressure
measurement using tip-pressure sensors: in vivo and in vitro
evaluation. J Vasc Surg 2004;40:711–6.
45. Ohki T, Ouriel K, Silveira PG, et al. Initial results of wireless pressure
sensing for endovascular aneurysm repair: the APEX Trial-
Acute Pressure Measurement to Confirm Aneurysm Sac EXclusion.
J Vasc Surg 2007;45:236–42.
46. Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal
aortic aneurysms clinical practice guidelines of the European society
for vascular surgery. Eur J Vasc Endovasc Surg 2011;41 Suppl 1:S1-S58.
47. Schaeffer JS, Shakhnovich I, Sieck KN, Kallies KJ, Davis CA, Cogbill TH.
Duplex Ultrasound Surveillance After Uncomplicated Endovascular
Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg
48. Pandey N, Litt HI. Surveillance Imaging Following Endovascular
Aneurysm Repair. Semin Intervent Radiol 2015;32:239–48.
49. Soares Ferreira R, Bastos Goncalves F. Next generation post EVAR
follow-up regime. J Cardiovasc Surg (Torino) 2017;58:875–82.