title: Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair.
abstract: BACKGROUND
  Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance.
  
  
  METHODS
  Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6-18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks.
  
  
  RESULTS
  Some 597 EVARs (71.1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47.6 per cent), moderate shrinkage (5-9 mm) in 142 (23.8 per cent) and major shrinkage (at least 10 mm) in 171 patients (28.6 per cent). Four years after the index imaging, the rate of freedom from complications was 84.3 (95 per cent confidence interval 78.7 to 89.8), 88.1 (80.6 to 95.5) and 94.4 (90.1 to 98.7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3.11; P < 0.001). Moderate compared with major shrinkage (HR 2.10; P = 0.022), early postoperative complications (HR 3.34; P < 0.001) and increasing abdominal aortic aneurysm baseline diameter (HR 1.02; P = 0.001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage.
  
  
  CONCLUSIONS
  Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
authors.forename: F
authors.initials: F
authors.lastname: Bastos Gonçalves
authors.forename: H
authors.initials: H
authors.lastname: Baderkhan
authors.forename: H J M
authors.initials: HJ
authors.lastname: Verhagen
authors.forename: A
authors.initials: A
authors.lastname: Wanhainen
authors.forename: M
authors.initials: M
authors.lastname: Björck
authors.forename: R J
authors.initials: RJ
authors.lastname: Stolker
authors.forename: S E
authors.initials: SE
authors.lastname: Hoeks
authors.forename: K
authors.initials: K
authors.lastname: Mani
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D001019:Aortic Rupture / Q000473:pathology / Q000601:surgery*; D016009:Chi-Square Distribution; D057867:Endoleak / Q000453:epidemiology / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D009426:Netherlands; D009929:Organ Size; D011859:Radiography; D012086:Reoperation / Q000706:statistics & numerical data; D013548:Sweden; D014463:Ultrasonography
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