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

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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