Meta-analysis of compliance with endovascular aneurysm repair surveillance: The EVAR surveillance paradox

Published:October 19, 2022DOI:
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      To compare the survival of patients who attended surveillance after endovascular aneurysm repair (EVAR) with those who were non-compliant.

      Data sources

      MEDLINE and Embase were searched using the Ovid interface.

      Review methods

      A systematic review was conducted complying with the PRISMA guidelines. Eligible studies compared survival in EVAR surveillance compliant patients versus non-compliant patients. Non-compliance was defined as failure to attend at least one post-EVAR follow-up. The risk of bias was assessed with the Newcastle-Ottawa scale, and the certainty of evidence using the GRADE framework. Primary outcomes were survival and aneurysm-related mortality. Effect measures were the hazard ratio (HR) or odd ratio (OR) and 95% confidence interval (CI) calculated using the inverse variance or Mantel-Haenszel statistical method and random-effects models.


      Thirteen cohort studies with a total of 22,762 patients were included. Eight studies were deemed high risk of bias. The pooled proportion of patients who were non-compliant with EVAR surveillance was 43% (95% CI 36%-51%). No statistically significant difference was found in the hazard of all-cause mortality (HR 1.04, 95% CI 0.61-1.77), aneurysm-related mortality (HR 1.80, 95% CI 0.85-3.80), or secondary intervention (HR 0.66, 95% CI 0.31-1.41) between patients who had incomplete and complete follow-up after EVAR. The odds of aneurysm rupture were lower in non-compliant patients (OR 0.63, 95% CI 0.39-1.01). The certainty of evidence was very low for all outcomes. Subgroup analysis for patients who had no surveillance versus those with complete surveillance showed no significant difference in all-cause mortality (HR 1.10, 95% CI 0.43-2.80).


      Patients who were non-compliant with EVAR surveillance had similar survival to those who were compliant. The findings question the value of intense surveillance in all patients post-EVAR and highlight the need for further research on individualized or risk-adjusted surveillance.


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      Linked Article

      • EVAR Surveillance: An Ongoing Dilemma or Time to Face the Hard Truth?
        European Journal of Vascular and Endovascular Surgery
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          The International Risk Stratification in Endovascular Aneurysm Repair (IRIS-EVAR) working group have conducted a robust meta-analysis to fuel the ongoing debate on the benefits of EVAR surveillance.1 The meta-analysis showed that, from a cohort of 13 studies with a total of 22 762 patients, compliance with EVAR surveillance was poor, as 43% of patients did not attend one or more imaging follow up scan appointments. Furthermore, there was no statistically significant difference in survival, aneurysm related mortality, re-intervention, or rupture rates between compliant and non-compliant patients.
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