Is 10-Year Follow-Up Really Enough After EVAR?

Ten-year follow-up (FU) after endovascular aneurysm repair (EVAR) is often treated as a meaningful milestone – long enough to reassure clinicians about device durability, and long enough for many patients’ competing risks to dominate outcomes. Yet Moritz Bischoff (Heidelberg University Hospital, Germany) positions that the question is not simply whether 10 years is ‘enough’, but what this means in a vascular population where all-cause mortality is high, late EVAR-related events can still occur, and loss to follow-up is a persistent threat. 

In conversation with LINC Today, Professor Bischoff discussed how late failure modes and sac dynamics should shape risk-adapted surveillance, why patient engagement may be the decisive determinant of long-term safety, and how imaging strategies can be tailored without losing sight of FU into the second decade and beyond.

At 10 years post-EVAR, EVAR-related events and all-cause outcomes can diverge, so which outcomes should we prioritize when judging whether FU is ‘enough’?

Speaking as a clinician, FU has to be as long as reasonably achievable. All-cause mortality is high in vascular patients and the rates of loss to FU are substantial. Additionally, there is a high rate of noncompliance. Thus, it takes a lot of effort to gather meaningful FU, including logistical premises and personal dedication and skills. Of course, the scientist in me votes for lifelong surveillance. However, there are conditions that we have to accept, i.e. a patient is too sick for FU.

Your 10-year registry data with the Gore C3 Excluder supports long-term durability but highlights surveillance adherence challenges. What are the most important late failure modes you still worry about beyond year 10? 

Technically, we have to watch out for type I and III endoleaks. However, I think the main threat to successful EVAR is diminishing FU engagement. No engagement, no FU. 

At 10 years, what’s the best ‘signal’ that a patient is truly low risk – stable/shrinking sac, no endoleak, or anatomical/instruction for use (IFU) factors? How confident are you that this predicts safety beyond 10 years? 

From what we know today, sac shrinkage is the key determinant for successful EVAR. It makes the utmost sense, and multiple studies have confirmed it. The broader picture of sac dynamics, including the topic of type II endoleaks, will require our attention in the years to come. The combination of IFU-conform implantation and traceable sac-shrinkage during FU seems pretty safe. However, as progression of disease plays an important part in late or very late complications, there is never a 100 % guarantee. That is why we need FU, even in low-risk patients. 

Guidelines are moving toward risk-adapted imaging intervals (including delayed imaging in selected low-risk patients). In 2026, do you think the trend is toward less imaging after year 1, or do late events still justify lifelong surveillance? 

Personally, I think that the surveillance approach in the current guidelines makes a lot of sense. The old ‘one size fits all FU’ approach is outdated and personalized FU schedules seem appropriate. However, evidence is still lacking and I’m looking forward to future studies. The aim of lifelong surveillance remains untouched for me. 

If 10 years isn’t enough, where do late events actually cluster – years 10–15, or is risk more continuous?  And what’s the practical implication for surveillance schedules?

From what we have seen, late events are rare, but they can happen. Within the European C3 cohort, we had no aortic rupture after the fourth year of FU, and device-related reinterventions were limited too. That being said, we all know that drastic things can happen in unfollowed EVAR patients. Thus, it is important to keep a continuous relationship with your patient throughout FU. Form an engagement before implantation, explain the future road to take, determine key FU dates, reinforce engagement and so on. An EVAR patient should not be a submarine with an unknown course, which may surface or not. You must keep them on the radar. 

How much of late risk is device-related versus biology/anatomy related? With newer generations and proven-durability devices, do you expect the ‘late EVAR penalty’ to narrow? 

Of course, there is natural disease progression, reducing former healthy landing zones. However, problems often start with improper implantations. Ignoring or deliberately stretching IFUs in elective EVAR is grossly negligent, given the technical opportunities we have today. The best device cannot compensate for thoughtless use.

In long-term FU, where do you see duplex (or non-contrast computed tomography [CT]/magnetic resonance [MR] angiography) fitting versus CTA – especially for renal function, radiation, and cost containment? 

In experienced hands, most scenarios can be handled by duplex ultrasound. In low-risk cases, a CTA should be performed at defined time-points (i.e. every five years), as suggested by the guidelines. In contrast, once there is a certain dynamic within the aneurysm sac, diameter progression, or flow caused by an endoleak, it’s time for an unscheduled CT scan. CTA should be more used for re-intervention planning than actual surveillance. Of course, this requires dedication and engagement from both sides, the treating physician and the patient.

How do you counsel a 60-year-old versus an 85-year-old EVAR patient about FU? Is there a point where competing mortality risk reasonably changes the surveillance intensity? 

Before performing surgery, I usually consider three questions. Firstly, is treatment necessary? Secondly, what’s the best treatment option, including potential risks and benefits? Finally, do I believe my operation will be beneficial to the patient? Naturally, the answers to these questions can vary significantly between a 60-year-old and an 85-year-old with an AAA. 

With respect to FU, I am looking for engagement – also before the implantation. If patients do not understand the benefits and risks of long-term FU, they are likely to be less compliant. I always tell the patient that getting an EVAR is like getting a new car. You have to take care of it, service it, and maintain it. Then it will serve you a very long time. It’s placative, but understandable – basically at any age. 

What evidence would you want to see to justify FU strategies more robustly in the future (if possible!)? A randomized strategy trial, registry-based threshold, or a validated risk score incorporating sac dynamics and early imaging?

Personally, I do not see a randomized controlled trial comparing surveillance strategies after EVAR. Instead, we have to settle for unbiased, high-quality observational evidence, including imaging FU. In future studies, long-term FU data could be captured within national vascular quality registers, which have automatic capture of survival data and re-interventions, thereby preventing dropout from FU.