Optimizing Surveillance and Re-intervention Strategy following Elective Endovascular Repair of Abdominal Aortic Aneurysms

Lois G. Kim*, Michael J. Sweeting, David Epstein, Maarit Venermo, Fiona E.V. Rohlffs, Roger M. Greenhalgh

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)


Background:EVAR for abdominal aortic aneurysm has an initial survival advantage over OR, but more frequent complications increase costs and long-term aneurysm-related mortality. Randomized controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient's lifetime. However, in the EVAR-1 trial, postoperative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked.Methods:Real-world data informed a discrete event simulation model of postoperative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from 5 alternative postoperative surveillance and re-intervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored.Results:Compared with observed EVAR-1 outcomes, modeling full adherence to the EVAR-1 scan protocol reduced abdominal aortic aneurysm (AAA) deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory computed tomography if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions.Conclusions:All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.

Original languageEnglish
Pages (from-to)E589-E598
JournalAnnals of Surgery
Issue number6
Publication statusPublished - 1 Dec 2021
Externally publishedYes

Bibliographical note

Funding Information:
This study was funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment program (project number 11/36/46). Additional support for this project for work done at the University of Cambridge came from the UK Medical Research Council (MR/L003120/1), the British Heart Foundation (RG/13/13/30194), and the NIHR (Cambridge Biomedical Research Centre at the Cambridge University Hospitals NHS Foundation Trust and the Camelia Botnar Arterial Foundation). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Funding Information:
L.G.K., D.E., F.R., and M.S. have no disclosures. M.V. is PI for the Voyager trial (Bayer; institution received reimbursement for patients included to the study). R.G. is supported by NIHR and Camelia Botnar Foundation and additionally has an equity share in Biba Medical Ltd. which is an event organizer and publisher.

Publisher Copyright:
© 2021 Lippincott Williams and Wilkins. All rights reserved.


  • abdominal aortic aneurysms
  • discrete event simulation
  • economic evaluation
  • endovascular aneurysm repair
  • surveillance


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