J Vasc Surg. 2026 Mar 13:S0741-5214(26)00215-6. doi: 10.1016/j.jvs.2026.02.042. Online ahead of print.
ABSTRACT
OBJECTIVE: To evaluate the impact of aneurysmal sac regression versus failure to regress on perioperative and long-term outcomes after endovascular aortic aneurysm repair (EVAR).
METHODS: Article screening was conducted using Medline, Embase, and the Cochrane databases. The primary outcome was overall survival; secondary outcomes included reintervention-free survival, endoleak during follow-up, aneurysmal rupture and reintervention during follow-up. End points were compared using risk ratio (RR) for binary outcomes and hazard ratio (HR) for long-term outcomes. For all outcomes, 95% confidence intervals were calculated. Subgroup analysis was done for studies including F/BEVAR patients and for studies comparing sac regression to sac stability. A trial sequential analysis was done for the short-term outcomes. Heterogeneity was assessed through the I2 statistic. GRADE assessment of the findings was performed.
RESULTS: Twenty-seven studies comprising 36,822 patients were included. Sac regression was associated with improved overall survival in the overall analysis (HR 0.70; 95% CI 0.61-0.80; p < .00001). In the F/BEVAR subgroup, sac regression was associated with a numerically lower hazard of death; however, this association did not reach statistical significance (HR 0.87; 95% CI 0.49-1.53; p = .62). This association persisted for endoleak during follow-up, with lower risk observed in the overall analysis (RR, 0.55; 95% CI, 0.41-0.72; p < .0001) and in the F/BEVAR subgroup (RR, 0.55; 95% CI, 0.41-0.75; p = .0001). Patients with sac regression also demonstrated better reintervention-free survival (HR, 0.37; 95% CI, 0.27-0.53; p < .00001) and a lower incidence of reintervention during follow-up and aneurysm rupture; however, these latter outcomes were not statistically significant within the F/BEVAR subgroup. Statistical significance persisted across all outcomes in the subgroup analysis comparing sac regression with stable sac.
CONCLUSION: Sac regression after EVAR confers superior outcomes compared with failure to regress. Our findings underscore the importance of sac behaviour as a key indicator in post-EVAR surveillance and long-term risk stratification.
PMID:41833592 | DOI:10.1016/j.jvs.2026.02.042
