title: Lost to follow-up: a potential under-appreciated limitation of endovascular aneurysm repair.
abstract: OBJECTIVE
  It has long been evident that lifetime follow-up after endovascular aneurysm repair (EVAR) is necessary to identify late complications. The purpose of this study is to test the hypothesis that late follow-up rates for EVAR in routine practice are inferior to those reported from protocol-driven clinical trials, consequently contributing to avoidable events associated with poor long-term outcome.
  
  
  METHODS
  From February 1999 to December 2005, 302 EVARs were performed and eligible for follow-up. Of these, 47 were performed as part of an industry-sponsored clinical trial (study patients). Responsibility for follow-up was assigned to a research nurse for study patients and to office clerical staff for nonstudy patients. Follow-up compliance was classified as either frequent (<1 missed scheduled appointment) or incomplete (>2 missed scheduled appointments). Overall survival and complication rates were analyzed.
  
  
  RESULTS
  Of the 302 patients, 203 (67.2%) had frequent follow-up and 99 (32.8%) had incomplete follow-up. The mean follow-up was significantly better in the frequent follow-up group (34.7 +/- 22 months) vs the incomplete follow-up group (18.8 +/- 18.6 months, P < .001). The 5-year survival (63.9% frequent vs 64.0% incomplete), the 5-year reintervention rate (22.3% frequent vs 10.8% incomplete), and incidence of known endoleak (14.8% frequent vs 9.1% incomplete) were statistically similar in the two groups. The incidence of major adverse events, defined as events requiring urgent surgical intervention, was significantly increased in the incomplete follow-up group (6.1% vs 0.5%; P = .006), with nearly half of these patients dying perioperatively. There was no difference in measured outcomes for study patients compared with nonstudy patients. However, mean follow-up was significantly longer for study patients vs nonstudy patients (44.8 +/- 23.7 months vs 26.8 +/- 20.9 months; P < .001).
  
  
  CONCLUSIONS
  Follow-up surveillance after EVAR is less intense in practice environments outside of clinical trials. Patients with incomplete follow-up have higher fatal complication rates than patients with frequent follow-up. These data expose a potential under-appreciated limitation of EVAR, questioning whether the findings in clinical trials defining the efficacy of EVAR can be routinely extrapolated to ordinary practice.
authors.affiliation: Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, SC 29605, USA.
authors.forename: Wesley B
authors.initials: WB
authors.lastname: Jones
authors.forename: Spence M
authors.initials: SM
authors.lastname: Taylor
authors.forename: Corey A
authors.initials: CA
authors.lastname: Kalbaugh
authors.forename: Charles S
authors.initials: CS
authors.lastname: Joels
authors.forename: Dawn W
authors.initials: DW
authors.lastname: Blackhurst
authors.forename: Eugene M
authors.initials: EM
authors.lastname: Langan
authors.forename: Bruce H
authors.initials: BH
authors.lastname: Gray
authors.forename: Jerry R
authors.initials: JR
authors.lastname: Youkey
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D019160:Endosonography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D013022:South Carolina / Q000453:epidemiology; D015996:Survival Rate; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome