What is the recommended follow-up for a patient with abdominal aortic aneurysm (AAA) status post (s/p) repair?

Follow-Up After AAA Repair

After endovascular AAA repair (EVAR), perform CT angiography and duplex ultrasound at 1 month, then annual duplex ultrasound with CT every 5 years; after open surgical repair, perform imaging at 1 year, then every 5 years if stable. 1, 2

Post-EVAR Surveillance Protocol

Initial Imaging (First Month)

• Perform both CT angiography (CTA) and duplex ultrasound (DUS) or contrast-enhanced ultrasound (CEUS) at 30 days post-procedure to establish baseline and assess treatment success 1, 2
• This 30-day imaging serves as the reference point for all future comparisons 2

Year 1-5 Surveillance

• If the 1-month scan shows no abnormalities, perform DUS/CEUS at 12 months 1, 2
• Continue annual DUS/CEUS surveillance through year 5 if no complications are detected 1, 2
• The traditional 6-month interval scan can be eliminated if the 1-month scan is normal 2

Long-Term Surveillance (After Year 5)

• Perform DUS/CEUS annually for ongoing monitoring 1
• Add CT or MRI every 5 years even when ultrasound findings remain normal 1, 2
• After 5 years without complications, continuing CT surveillance every 5 years is reasonable 1

High-Risk Situations Requiring Intensified Monitoring

• Repeat CT every 6-12 months if aneurysm sac growth occurs without type I or III endoleak, with interval determined by growth rate 1, 2
• Perform CT every 3-6 months if any abnormalities are documented at any follow-up timepoint 1
• Older patients, inadequate sealing, type II endoleaks, or lack of early sac shrinkage warrant more frequent evaluation 1

Post-Open Repair Surveillance Protocol

Initial and Long-Term Imaging

• Perform first imaging study within 1 year after open AAA repair 1
• Continue imaging every 5 years thereafter if findings remain stable 1
• Open repair has significantly lower complication rates (2-4%) compared to EVAR (16-30%), allowing for less intensive surveillance 1, 2

Management of Endoleaks

Type I and III Endoleaks

• Re-intervene immediately to achieve a seal for type I endoleaks (proximal or distal attachment site leaks) 1, 2
• Re-intervene, principally by endovascular means, for type III endoleaks (graft fabric tears or component separation) 1, 2

Type II and V Endoleaks

• Consider re-intervention with endovascular approach or embolization when type II or V endoleak is associated with significant sac expansion ≥10 mm or significantly decreasing proximal/distal seal 1, 2

Imaging Modality Selection

Standard Modalities

• Use DUS as the primary surveillance tool for routine follow-up after EVAR 1
• Switch to CT or MRI if DUS does not allow adequate measurement of AAA diameter 1
• If any abnormality is detected on DUS/CEUS, confirm with additional CT or MRI based on potential artifacts 1

Radiation Considerations

• Consider CMR instead of CT when frequent controls are required, particularly after the first year of follow-up, to minimize cumulative radiation exposure 1
• This is especially important in younger patients and women who require long-term surveillance 1

Essential Medical Management

Cardiovascular Risk Reduction

• Implement optimal cardiovascular risk management to reduce major adverse cardiovascular events (MACE) in all AAA patients post-repair 1, 2
• Prescribe statin therapy, which is associated with decreased short- and long-term mortality after both surgical and endovascular AAA repair 1, 2

Surveillance for New Aneurysms

• Assess for aneurysm development or growth in other arterial segments during follow-up visits 1
• The 5-year mortality rate remains elevated (4-fold higher in women, 2-fold higher in men) despite successful AAA repair due to cardiovascular disease in other vascular beds 1

Common Pitfalls to Avoid

• Do not rely solely on ultrasound for long-term surveillance—periodic CT or MRI is necessary even with normal ultrasound findings 1, 2
• Do not extend surveillance intervals prematurely—EVAR requires lifelong monitoring due to high complication rates 2
• Avoid fluoroquinolone antibiotics in AAA patients unless there is a compelling indication with no reasonable alternative 1
• Real-world adherence to surveillance guidelines is poor (only 43% complete surveillance in Medicare beneficiaries), with male sex, lack of primary care provider, and longer distance from hospital associated with incomplete follow-up 3—proactive patient engagement and coordination are essential