Next generation post EVAR follow-up regime

Durability of endovascular aneurysm repair is critical, since a significant proportion of patients suffer from procedure-related complications and secondary interventions after repair of abdominal aortic aneurysms. Therefore, regular follow up including imaging is recommended. The rationale behind current surveillance programs is to allow early detection and elective treatment of complications. However, current recommendations are laborious and resource consuming, may be deleterious to many patients and are largely inefficient. Furthermore, they do not account for novel imaging modalities or for the use of new endovascular devices. The authors review the current recommendations from international societies, and of the evidence for new imaging modalities that could be as alternatives, namely contrast enhanced ultrasound, three-dimensional contrast-enhanced ultrasound and digital tomosynthesis. The evidence on surveillance after repair with new devices, specifically with sealing technology, and its imaging specificities is also discussed. Lastly, the authors review the evidence for risk stratification of surveillance. Stratified follow up regimes may be based on preoperative anatomical characteristics or on postoperative imaging results, at different time points. Effective sealing, absence of endoleaks and sac dynamics are the most commonly used factors for stratification. In conclusion, there is still no consensus on surveillance after endovascular aneurysm repair, with regard to both modality and timing. Novel devices, and especially those using sealing technology, require more intensive surveillance as the expected results at mid- and long-term remain undetermined. Risk stratification of follow-up seems possible but still requires prospective validation before generalization.