Long-term surveillance after EVAR and TEVAR: Are Patients Truly Lost to Follow-Up?

The importance of long-term follow-up and surveillance (LTFUS) after endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) is well documented. However, defining LTFUS in a manner that is clinically meaningful remains incompletely characterized. The increasing availability of integrated electronic medical records (EMR) and health information exchange (HIE) systems present an opportunity to explore LTFUS after EVAR/TEVAR. We evaluated whether utilizing HIE within a single healthcare system may facilitate LTFUS assessment without direct patient contact.

We performed a single-center retrospective review of patients who underwent EVAR/TEVAR and were enrolled in the Vascular Quality Initiative (VQI) from 2011-2022. All patients deemed lost to long term follow-up according to VQI definitions of 9-21 months (LTFUS-VQI) were reviewed in the EMR enhanced by HIE (LTFUS-HIE). Radiology reports and documents available through EMR and HIE were reviewed (aortic abdominal ultrasounds, computed tomography (CT) images, and magnetic resonance imaging/angiography (MRI/MRA)). Suitable LTFUS was defined as imaging data sufficient for clinical care and decision making, including aneurysm diameter and/or presence or absence of endoleak. LTFUS-VQI and LTFUS-HIE compliance was compared.

Among 461 EVAR/TEVARs from a single institution, 214 (46.4%) patients were considered lost to follow-up by VQI criteria. 102 of these patients (47.7%), however, had imaging following their repair when using HIE. Inclusion of HIE data and expanding the duration of LTFUS to beyond 21 months reduced the true lost to follow-up rate to 24.3% (112/461) compared to VQI criteria defined lost to follow-up of 46.4% (214/461). Over 30% of all HIE data was obtained from outside the hospital system or state of the index surgery. In the LTFUS-HIE group, 49.5% underwent dedicated imaging for aneurysm surveillance, while 27.1% underwent incidental imaging containing sufficient aortic information. When comparing preoperative measurements to most recent imaging evaluating aortic remodeling, 19.4% of patients meeting LTFUS-VQI criteria had aneurysm expansion, compared to 22.5% of patients with HIE available surveillance reports. A significantly greater proportion of patients in the VQI cohort demonstrated a decrease in aneurysm size greater than 5 mm compared to the HIE cohort (35.6% vs 16.7%, p <0.001).

A large proportion of patients deemed lost to follow-up by VQI-criteria were not lost to overall care, suggesting that passive surveillance strategies leveraging EMR and HIE may improve longitudinal monitoring without direct patient contact. These findings have important implications for how surveillance is investigated and reported, as VQI definitions of long-term follow-up remain a cornerstone in published literature and guidelines on outcomes of endovascular aortic surgery.