Vascular Surgery Follow-Up

Carotid Artery

  • Carotid endarterectomy and stenting have similar restenosis rates (3-6% at 2 years)
  • Even in the setting of restenosis, percentage of symptomatic patients remain small. For asymptomatic  patients with >80% restenosis, reintervention can be considered but is not well supported by evidence.
  • The first baseline ultrasound exam after index procedure should be done soon, preferably within 3 months.
  • It is then 6 months for 2 years, then annually until stable (no restenosis for 2 consecutive annual scans)
  • If after 2 consecutive annual scans (this puts the patient 4 years since the index intervention), it is recommended that some interval of regular surveillance for the life of the patient should be maintained, such as every 2 years

Modified in-stent velocities should be used as below to estimate degree of in-stent stenosis, as the presence of the stent changes the compliance of the artery:

ISR, % diameter reduction Velocity criteria
≥20 PSV ≥150 cm/s and ICA/CCA ratio ≥2.15
≥50 PSV ≥220 cm/s and ICA/CCA ratio ≥2.7
≥80 PSV ≥340 cm/s and ICA/CCA ratio ≥4.15

Thoracic Aortic Repair

TEVAR

  • Endoleak occurs approximately 30% of aneurysm patients after TEVAR.
  • Type I and III endoleaks require immediate repair as they are considered treatment failures due to persistent aneurysm sac pressurization
  • Most type II endoleaks originate from the left subclavian artery and 56% of these require repair at 2 years
  • TEVAR for aneurysmal disease, regular follow ups are recommended due to propensity for contiguous aneurysmal degeneration
    • CTA at 1 month and 12 months after TEVAR, then annually thereafter. If 1 month scan shows abnormality, a 6-month CTA should be considered
  • TEVAR for blunt trauma follow ups may be less intense but not completely excluded as long term outcomes remain unclear
    • Currently, recommended follow up protocol is the same as above, but long-term intervals could be lessened
  • TEVAR for dissection should be monitored closely due to aortic remodeling
    • CTA at 1 month, 6, months, and 12 months, then annually after

Open thoracic aneurysm repair

  • CTA at 5-year intervals

Abdominal Aortic Aneurysm Repair

EVAR

  • CTA at 1 and 12 months, with more frequent imaging considered if 1-month scan shows endoleak or other concerns
  • 12-month DUS interval surveillance if no endoleak or sac enlargement was found during first year
  • DUS and non-contrast CT scans as alternative imaging for patients with contraindication to iodinated contrast

Open repair

  • Regardless of open repair or EVAR, 5-year total aortic non-contrast CT scan to detect aneurysmal degeneration of other aortic segments

Mesenteric Stenting or Bypass

  • Clinical follow up and duplex ultrasound within 1 month of index procedure
  • Clinical follow-up and duplex ultrasound at 6 month, 12 months, and yearly thereafter
  • Fasting is essential prior to the duplex exam to decrease bowel gas interference

See mesenteric artery duplex criteria for stenosis threshold.

Renal Artery Stenting

  • Follow-up schedule is the same as mesenteric artery
  • Clinical follow up and duplex ultrasound within 1 month of index procedure
  • Clinical follow-up and duplex ultrasound at 6 month, 12 months, and yearly thereafter

See renal artery duplex criteria for stenosis threshold.

Source: SVS practice guidelines https://www.jvascsurg.org/article/S0741-5214(18)30896-6/fulltext