Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Postoperative surveillance after abdominal aortic aneurysm repair

•Endovascular aneurysm repair (EVAR) is associated with a risk of late endograft failure and secondary rupture.1Antoniou G.A. Antoniou S.A. Torella F. Endovascular vs. open repair for abdominal aortic aneurysm: systematic review and meta-analysis of updated perioperative and long term data of randomised controlled trials.Eur J Vasc Endovasc Surg. 2020; 59: 385-397Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar•A para-anastomotic aneurysm or aneurysmal dilatation of the visceral aortic segment will occur in 1%, 5%, and 20% of patients at 5, 10, and 15 years, respectively, after open surgical repair (OSR).•Postoperative surveillance is required to reduce the risk of late rupture and aneurysm-related death after both EVAR and OSR.Recommendations for postoperative surveillanceSurveillance recommendations include the following (Fig)2Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B.M. Lee W.A. Mansour M.A. et al.The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67: 2-77Abstract Full Text Full Text PDF PubMed Scopus (1027) Google Scholar:•Baseline imaging studies within the first month after EVAR with contrast-enhanced computed tomography (CT) and color duplex ultrasound (DUS).•If endoleak or sac enlargement is identified, imaging studies should be repeated at 6 months (grade 2B evidence level).•In the absence of an endoleak or sac enlargement, color DUS, when feasible, or contrast-enhanced CT if DUS is not possible, is suggested for annual surveillance (grade 1B evidence level).•Identification of a new endoleak, graft migration, or sac growth of ≥5 mm on color DUS should prompt contrast-enhanced CT imaging studies.•Non–contrast-enhanced CT imaging studies of the entire aorta should be obtained at 5-year intervals after OSR or EVAR (grade 2C evidence level).Rationale•If contrast-enhanced CT imaging studies demonstrate neither aneurysm enlargement nor endoleak at 1 year after EVAR, color DUS can be considered as the primary imaging modality for annual surveillance.3Zaiem F. Almasri J. Tello M. Prokop L.J. Chaikof E.L. Murad M.H. A systematic review of surveillance after endovascular aortic repair.J Vasc Surg. 2018; 67: 320-331Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,4Sternbergh III, W.C. Greenberg R.K. Chuter T.A. Tonnessen B.H. 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: 278-284Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar•DUS-based surveillance eliminates radiation exposure, minimizes cost, and avoids the use of nephrotoxic contrast agents.•In contemporary real-world conditions, the results from the prospective, multicenter, blinded ESSEA (computed tomography scan vs color duplex ultrasound for surveillance of endovascular repair of abdominal aortic aneurysm. a prospective multicenter study) trial highlighted that color DUS is less sensitive than contrast-enhanced CT imaging in detecting a failing repair.5Jean-Baptiste E. Feugier P. Cruzel C. Sarlon-Bartoli G. Reix T. Steinmetz E. et al.Computed tomography-aortography versus color-duplex ultrasound for surveillance of endovascular abdominal aortic aneurysm repair: a prospective multicenter diagnostic-accuracy study (the ESSEA trial).Circ Cardiovasc Imaging. 2020; 13: e009886Crossref PubMed Scopus (8) Google Scholar•The factors that limit the sensitivity of color DUS in post-EVAR surveillance include patient habitus, bowel gas, embolic coils, aortic calcification, and operator experience.Commentary and future directions•The development of validated strategies to improve patient compliance with post-EVAR surveillance represents a critical need, with recent reports noting ≥50% nonadherence at 5 years.6Garg T. Baker L.C. Mell M.W. Postoperative surveillance and long-term outcomes after endovascular aneurysm repair among Medicare beneficiaries.JAMA Surg. 2015; 150: 957-963Crossref PubMed Scopus (46) Google Scholar•Risk prediction models for endograft failure using pre- or postoperative factors might assist in identifying an optimal frequency, modality, and imaging duration for post-EVAR surveillance that is risk stratified.•A systematic review of post-EVAR surveillance protocols noted that current risk-stratified recommendations for intensive or less frequent surveillance have not been validated by prospective studies.7Patel S.R. Allen C. Grima M.J. Brownrigg J.R.W. Patterson B.O. Holt P.J.E. et al.A systematic review of predictors of reintervention after EVAR: guidance for risk-stratified surveillance.Vasc Endovascular Surg. 2017; 51: 417-428Crossref PubMed Scopus (24) Google Scholar•The noninferiority of color DUS as an alternative to contrast-enhanced CT imaging studies for annual post-EVAR surveillance has not been demonstrated by randomized prospective studies. •Endovascular aneurysm repair (EVAR) is associated with a risk of late endograft failure and secondary rupture.1Antoniou G.A. Antoniou S.A. Torella F. Endovascular vs. open repair for abdominal aortic aneurysm: systematic review and meta-analysis of updated perioperative and long term data of randomised controlled trials.Eur J Vasc Endovasc Surg. 2020; 59: 385-397Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar•A para-anastomotic aneurysm or aneurysmal dilatation of the visceral aortic segment will occur in 1%, 5%, and 20% of patients at 5, 10, and 15 years, respectively, after open surgical repair (OSR).•Postoperative surveillance is required to reduce the risk of late rupture and aneurysm-related death after both EVAR and OSR. Recommendations for postoperative surveillanceSurveillance recommendations include the following (Fig)2Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B.M. Lee W.A. Mansour M.A. et al.The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67: 2-77Abstract Full Text Full Text PDF PubMed Scopus (1027) Google Scholar:•Baseline imaging studies within the first month after EVAR with contrast-enhanced computed tomography (CT) and color duplex ultrasound (DUS).•If endoleak or sac enlargement is identified, imaging studies should be repeated at 6 months (grade 2B evidence level).•In the absence of an endoleak or sac enlargement, color DUS, when feasible, or contrast-enhanced CT if DUS is not possible, is suggested for annual surveillance (grade 1B evidence level).•Identification of a new endoleak, graft migration, or sac growth of ≥5 mm on color DUS should prompt contrast-enhanced CT imaging studies.•Non–contrast-enhanced CT imaging studies of the entire aorta should be obtained at 5-year intervals after OSR or EVAR (grade 2C evidence level). Surveillance recommendations include the following (Fig)2Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B.M. Lee W.A. Mansour M.A. et al.The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67: 2-77Abstract Full Text Full Text PDF PubMed Scopus (1027) Google Scholar:•Baseline imaging studies within the first month after EVAR with contrast-enhanced computed tomography (CT) and color duplex ultrasound (DUS).•If endoleak or sac enlargement is identified, imaging studies should be repeated at 6 months (grade 2B evidence level).•In the absence of an endoleak or sac enlargement, color DUS, when feasible, or contrast-enhanced CT if DUS is not possible, is suggested for annual surveillance (grade 1B evidence level).•Identification of a new endoleak, graft migration, or sac growth of ≥5 mm on color DUS should prompt contrast-enhanced CT imaging studies.•Non–contrast-enhanced CT imaging studies of the entire aorta should be obtained at 5-year intervals after OSR or EVAR (grade 2C evidence level). Rationale•If contrast-enhanced CT imaging studies demonstrate neither aneurysm enlargement nor endoleak at 1 year after EVAR, color DUS can be considered as the primary imaging modality for annual surveillance.3Zaiem F. Almasri J. Tello M. Prokop L.J. Chaikof E.L. Murad M.H. A systematic review of surveillance after endovascular aortic repair.J Vasc Surg. 2018; 67: 320-331Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,4Sternbergh III, W.C. Greenberg R.K. Chuter T.A. Tonnessen B.H. 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: 278-284Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar•DUS-based surveillance eliminates radiation exposure, minimizes cost, and avoids the use of nephrotoxic contrast agents.•In contemporary real-world conditions, the results from the prospective, multicenter, blinded ESSEA (computed tomography scan vs color duplex ultrasound for surveillance of endovascular repair of abdominal aortic aneurysm. a prospective multicenter study) trial highlighted that color DUS is less sensitive than contrast-enhanced CT imaging in detecting a failing repair.5Jean-Baptiste E. Feugier P. Cruzel C. Sarlon-Bartoli G. Reix T. Steinmetz E. et al.Computed tomography-aortography versus color-duplex ultrasound for surveillance of endovascular abdominal aortic aneurysm repair: a prospective multicenter diagnostic-accuracy study (the ESSEA trial).Circ Cardiovasc Imaging. 2020; 13: e009886Crossref PubMed Scopus (8) Google Scholar•The factors that limit the sensitivity of color DUS in post-EVAR surveillance include patient habitus, bowel gas, embolic coils, aortic calcification, and operator experience. •If contrast-enhanced CT imaging studies demonstrate neither aneurysm enlargement nor endoleak at 1 year after EVAR, color DUS can be considered as the primary imaging modality for annual surveillance.3Zaiem F. Almasri J. Tello M. Prokop L.J. Chaikof E.L. Murad M.H. A systematic review of surveillance after endovascular aortic repair.J Vasc Surg. 2018; 67: 320-331Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,4Sternbergh III, W.C. Greenberg R.K. Chuter T.A. Tonnessen B.H. 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: 278-284Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar•DUS-based surveillance eliminates radiation exposure, minimizes cost, and avoids the use of nephrotoxic contrast agents.•In contemporary real-world conditions, the results from the prospective, multicenter, blinded ESSEA (computed tomography scan vs color duplex ultrasound for surveillance of endovascular repair of abdominal aortic aneurysm. a prospective multicenter study) trial highlighted that color DUS is less sensitive than contrast-enhanced CT imaging in detecting a failing repair.5Jean-Baptiste E. Feugier P. Cruzel C. Sarlon-Bartoli G. Reix T. Steinmetz E. et al.Computed tomography-aortography versus color-duplex ultrasound for surveillance of endovascular abdominal aortic aneurysm repair: a prospective multicenter diagnostic-accuracy study (the ESSEA trial).Circ Cardiovasc Imaging. 2020; 13: e009886Crossref PubMed Scopus (8) Google Scholar•The factors that limit the sensitivity of color DUS in post-EVAR surveillance include patient habitus, bowel gas, embolic coils, aortic calcification, and operator experience. Commentary and future directions•The development of validated strategies to improve patient compliance with post-EVAR surveillance represents a critical need, with recent reports noting ≥50% nonadherence at 5 years.6Garg T. Baker L.C. Mell M.W. Postoperative surveillance and long-term outcomes after endovascular aneurysm repair among Medicare beneficiaries.JAMA Surg. 2015; 150: 957-963Crossref PubMed Scopus (46) Google Scholar•Risk prediction models for endograft failure using pre- or postoperative factors might assist in identifying an optimal frequency, modality, and imaging duration for post-EVAR surveillance that is risk stratified.•A systematic review of post-EVAR surveillance protocols noted that current risk-stratified recommendations for intensive or less frequent surveillance have not been validated by prospective studies.7Patel S.R. Allen C. Grima M.J. Brownrigg J.R.W. Patterson B.O. Holt P.J.E. et al.A systematic review of predictors of reintervention after EVAR: guidance for risk-stratified surveillance.Vasc Endovascular Surg. 2017; 51: 417-428Crossref PubMed Scopus (24) Google Scholar•The noninferiority of color DUS as an alternative to contrast-enhanced CT imaging studies for annual post-EVAR surveillance has not been demonstrated by randomized prospective studies. •The development of validated strategies to improve patient compliance with post-EVAR surveillance represents a critical need, with recent reports noting ≥50% nonadherence at 5 years.6Garg T. Baker L.C. Mell M.W. Postoperative surveillance and long-term outcomes after endovascular aneurysm repair among Medicare beneficiaries.JAMA Surg. 2015; 150: 957-963Crossref PubMed Scopus (46) Google Scholar•Risk prediction models for endograft failure using pre- or postoperative factors might assist in identifying an optimal frequency, modality, and imaging duration for post-EVAR surveillance that is risk stratified.•A systematic review of post-EVAR surveillance protocols noted that current risk-stratified recommendations for intensive or less frequent surveillance have not been validated by prospective studies.7Patel S.R. Allen C. Grima M.J. Brownrigg J.R.W. Patterson B.O. Holt P.J.E. et al.A systematic review of predictors of reintervention after EVAR: guidance for risk-stratified surveillance.Vasc Endovascular Surg. 2017; 51: 417-428Crossref PubMed Scopus (24) Google Scholar•The noninferiority of color DUS as an alternative to contrast-enhanced CT imaging studies for annual post-EVAR surveillance has not been demonstrated by randomized prospective studies.