From the Guidelines
Regular follow-up care after Endovascular Aneurysm Repair (EVAR) should include baseline surveillance imaging with CT at 1 month, and then duplex ultrasound at 12 months and annually thereafter if there is no evidence of endoleak or sac enlargement, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. This approach is supported by the most recent and highest quality evidence, which emphasizes the importance of surveillance in detecting potential complications such as endoleaks, device migration, or aneurysm sac enlargement. The use of CT angiography with contrast is recommended for initial surveillance, but duplex ultrasound can be used for subsequent annual follow-up to reduce radiation exposure. Additionally, patients should continue taking antiplatelet therapy, such as aspirin 81mg daily, indefinitely after EVAR to prevent graft thrombosis, and blood pressure control is essential with a target of less than 140/90 mmHg using appropriate antihypertensive medications, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. Smoking cessation is also critical, as continued smoking significantly increases the risk of complications, and patients should report any symptoms such as abdominal or back pain, which could indicate aneurysm expansion, or leg pain/numbness, which might suggest graft limb occlusion. The 2022 ACC/AHA guideline also recommends additional cross-sectional imaging with CT or MRI every 5 years postoperatively in patients with AAA treated with EVAR who are undergoing annual surveillance imaging with duplex ultrasound 1. Similarly, the 2024 ESC guidelines recommend follow-up imaging with CCT (or CMR) and DUS/CEUS at 1 month and 12 months post-operatively, then, if no abnormalities are documented, DUS/CEUS is recommended every year, repeating CCT or CMR every 5 years 1. It is essential to note that the choice of imaging modality and follow-up schedule may vary depending on individual patient factors and institutional preferences, but the overall goal is to detect potential complications early and prevent long-term morbidity and mortality. The ACR Appropriateness Criteria also support the use of CT angiography and duplex ultrasound for post-EVAR surveillance, and recommend considering MRI as an alternative to CT in patients who are at risk for contrast-induced nephropathy or have a history of radiation exposure 1. Overall, a rigorous follow-up schedule is necessary after EVAR to monitor for potential complications and ensure the long-term success of the procedure, as emphasized by the 2022 ACC/AHA guideline and the 2024 ESC guidelines 1.
From the Research
Follow-up Care after Endovascular Aneurysm Repair (EVAR)
The recommended follow-up care after EVAR includes:
- Lifelong postoperative surveillance to prevent and identify complications early 2, 3
- Imaging surveillance to detect potential complications such as endoleaks, which can predispose the aorta to rupture 3
- Stratification of patients based on their risk of complications to determine the frequency of follow-up care 2, 4
Imaging Modalities for Follow-up Care
The following imaging modalities can be used for follow-up care after EVAR:
- Computed Tomography Angiography (CTA) within 30 days after EVAR to triage patients appropriately and guide future imaging 3
- Duplex ultrasound for annual monitoring of patients without endoleak on initial CTA 3
- Color Doppler ultrasound as a primary tool for surveillance, with CTA reserved for cases of aneurysm sac enlargement, detection of an endoleak, or inadequate ultrasound results 5
- Magnetic Resonance Angiography (MRA) as a problem-solving modality or in patients with contraindications to contrast media or radiation 3
Frequency of Follow-up Care
The frequency of follow-up care after EVAR depends on the patient's risk of complications:
- Patients with low risk of complications may require less frequent follow-up care, with some studies suggesting that less vigilant follow-up may be considered for these patients 2
- Patients with high risk of complications, such as those with hostile neck anatomy, may require more frequent surveillance 3
- The European Society for Vascular Surgery guidelines suggest stratifying surveillance after EVAR based on patient risk factors, with a combination of post-operative CTA and sac shrinkage at one year proposed as a method for stratification 4
Benefits and Limitations of Follow-up Care
The benefits of follow-up care after EVAR include:
- Early detection of complications such as endoleaks, which can reduce the risk of rupture and improve patient outcomes 3
- Stratification of patients based on their risk of complications, which can help tailor follow-up care to individual patient needs 2, 4 The limitations of follow-up care after EVAR include:
- Increased cost and workload associated with lifelong surveillance 2
- Potential for unnecessary reinterventions in patients who are compliant with imaging surveillance 6