title: Endovascular aneurysm repair patients who are lost to follow-up have worse outcomes.
abstract: Society for Vascular Surgery practice guidelines recommend 1- and 12-month follow-up with computed tomography imaging for the year after endovascular aneurysm repair (EVAR). We describe the incidence, risk factors, and outcomes of EVAR patients who are lost to follow-up (LTF).
  
  
  
  All patients undergoing elective EVAR in the Vascular Quality Initiative (VQI) data set (January 2003-December 2015) were stratified according to long-term follow-up method (in-person vs phone call vs LTF). Mortality was captured for all patients by linkage with the Social Security Death Index. Univariable statistics, Kaplan-Meier estimated survival curves, and Cox proportional hazard modeling were used to compare groups. Coarsened exact matching analysis was then performed to refine the association between LTF and risk of post-EVAR death.
  
  
  
  During the study period, 11,309 patients underwent elective EVAR (78% in-person follow-up, 11% phone call follow-up, 11% LTF). On univariable analysis, LTF patients had larger baseline aneurysms, higher American Society of Anesthesiologists scores, more comorbidities, and worse baseline functional status compared to patients with in-person or phone call follow-up (P ≤ .05). Procedural factors (contrast material volume, blood transfusions, postoperative vasopressor use) were higher in the LTF group, as was the incidence of postoperative complications (P ≤ .05). Accordingly, LTF patients had longer postoperative lengths of stay and were less frequently discharged to home (P < .001). Five-year survival was lower for LTF vs phone call follow-up vs in-person follow-up (62% vs 68% vs 84%; P < .001). On multivariable analysis correcting for baseline differences between groups, there was a significantly higher risk of death for both the LTF group (hazard ratio, 6.45; 95% confidence interval, 4.89-8.51) and phone call follow-up group (hazard ratio, 3.48; 95% confidence interval, 2.66-4.57) compared with patients who followed up in person (P < .001). After coarsened exact matching on 30 preoperative and perioperative variables, 5-year survival after EVAR for LTF vs phone call follow-up vs in-person follow-up was 84.9% vs 84.8% vs 91.9%, respectively (log-rank, P < .001). Notably, patients with phone call follow-up had a lower prevalence of documented postoperative imaging compared with patients with in-person follow-up (56.1% vs 85.1%; P < .001).
  
  
  
  EVAR patients with more comorbidities and a higher incidence of in-hospital complications tend to be more frequently LTF and ultimately have worse survival outcomes. In-person follow-up is associated with better post-EVAR survival and a higher rate of postoperative imaging. Phone follow-up confers a mortality risk equivalent to lack of follow-up, possibly as a result of inadequate postoperative imaging. Surgeons should stress the importance of office-based postoperative follow-up to all EVAR patients, particularly those with poor baseline health and functional status and more complicated perioperative courses.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md. Electronic address: chicks11@jhmi.edu.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Devin S
authors.initials: DS
authors.lastname: Zarkowsky
authors.affiliation: Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Ian C
authors.initials: IC
authors.lastname: Bostock
authors.affiliation: Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: David H
authors.initials: DH
authors.lastname: Stone
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Maine Medical Center, Portland, Me.
authors.forename: Jens
authors.initials: J
authors.lastname: Eldrup-Jorgensen
authors.affiliation: Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D015897:Comorbidity; D016208:Databases, Factual; D003952:Diagnostic Imaging / Q000379:methods; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D059012:Lost to Follow-Up; D008297:Male; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000401:mortality; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013689:Telephone; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology