# Follow up Imaging Protocols after Endovascular Aneurysm Repair: Results of the International FOREVAR Survey

## TL;DR

A global survey found significant variation in imaging protocols used to monitor patients after endovascular aortic repair, with no consensus on the best approach.

## Contribution

The study reveals global inconsistencies in follow-up imaging practices after endovascular aneurysm repair, highlighting a lack of standardized protocols.

## Key findings

- Most centers use standardized follow-up imaging protocols after endovascular aneurysm repair.
- CTA is most commonly used at initial follow-up, while duplex ultrasound is preferred for later monitoring.
- Follow-up imaging often continues indefinitely, leading to long-term radiation exposure for many patients.

## Abstract

Endovascular repair for aortic aneurysms necessitates routine follow up due to potential late complications, such as endograft occlusions, endoleaks, and late aneurysm rupture. Guidelines recommend periodic post-operative imaging, including computed tomography angiography (CTA) or duplex ultrasound, to monitor aneurysm status and stent integrity. The efficacy of these follow up protocols is controversial, with concerns about increased healthcare costs and patient morbidity. This survey aimed to assess global variance in follow up imaging protocols among vascular surgeons, interventional radiologists, and vascular surgery trainees.

A global English web based survey was conducted over nine months and distributed through email, social media, and direct messaging to vascular surgeons, interventional radiologists, and other vascular specialists. Procedure specific questions included imaging techniques used and follow up duration.

The FOREVAR Survey was completed by 693 respondents from 65 countries. Most participants reported having a standardised follow up imaging protocol following all, or nearly all, elective endovascular aneurysm repairs (EVAR) in their centre (98%). The follow up protocols displayed substantial variation. In addition to completion angiography, other imaging was often performed before discharge (cone beam computed tomography 11%, CTA 27%, or DUS 17%). CTA is most often performed at first follow up (63%), while DUS is most frequently used during later follow up (56%). Median intervals to follow up imaging were eight weeks (first), 39 weeks (second), and 52 weeks (third). Follow up never ceased in 51% of cases. Comparable results were reported for complex EVAR (cEVAR) and thoracic EVAR (TEVAR), but with a greater proportion of patients receiving CTA after cEVAR at long term follow up (74%). Magnetic resonance imaging was used by a minority in the follow up of EVAR, cEVAR, and TEVAR (4%, 1%, and 4%, respectively).

This global survey showed substantial variation in follow up imaging protocols after EVAR, cEVAR, and TEVAR. Most of these protocols lead to long term radiation exposure during follow up.

•There was great global variation in follow up after endovascular aortic repair.•Countries differed in the type and frequency of imaging used.•There was variation in length of follow up and median interval to follow up imaging.•Complex and thoracic repair frequently had similar protocols to standard repair.•There was a lack of consensus on which imaging follow up protocol was considered optimal.

There was great global variation in follow up after endovascular aortic repair.

Countries differed in the type and frequency of imaging used.

There was variation in length of follow up and median interval to follow up imaging.

Complex and thoracic repair frequently had similar protocols to standard repair.

There was a lack of consensus on which imaging follow up protocol was considered optimal.