Geographic disparities in perioperative and mid-term outcomes after elective infrarenal endovascular aneurysm repair

<h2>Abstract</h2><h3>Objective</h3> This study aimed to assess the impact of geographic location on mid-term postoperative outcomes after EVAR across 4 Canadian tertiary care institutions. We hypothesized that patients from rural or non-local areas may experience worse perioperative outcomes because of loss to follow-up, care transfers, and suboptimal surveillance. These factors could contribute to increased non-index readmissions and higher mortality rates following elective endovascular aneurysm repair (EVAR). <h3>Methods</h3> Elective infrarenal EVAR patients from four Canadian tertiary care institutions were assessed through a retrospective analysis of the Vascular Quality Initiative (VQI) database, stratified by rural versus urban postal codes. A subgroup analysis was also conducted using a 10-year retrospective dataset from Toronto General Hospital (TGH) and the VQI to evaluate EVAR outcomes based on patient geography. Primary outcomes included differences in loss to follow-up, overall survival, and reintervention-free survival. Secondary outcomes included differences in baseline characteristics, perioperative outcomes, and imaging surveillance. Statistical analyses consisted of t-tests for continuous variables, chi-square tests for categorical variables, and Kaplan-Meier survival analysis with log-rank tests. <h3>Results</h3> Elective EVAR outcomes from four Canadian hospitals (n=1,342 patients) were analyzed by rural versus urban status. Rural patients demonstrated higher postoperative imaging rates but were more likely to be lost to follow-up. Aggregate data revealed a survival advantage for urban patients at 12 months postoperatively. A subgroup analysis from a single tertiary care institution included 491 patients who underwent elective infrarenal EVAR. Patients were categorized by postal code as local versus non-local (80.9% and 19.1%, respectively) and urban versus rural (94.9% and 5.1%, respectively). The median follow-up duration was 32 months (IQR 51). Local and urban patients had significantly higher rates of follow-up within the first two months (local: 84.6% vs. non-local: 57.4%, p<0.001; urban: 80.2% vs. rural: 64.0%, p=0.050) and more frequent imaging between 6 and 12 months (local: 69.5% vs. non-local: 43.6%, p<0.001; urban: 65.9% vs. rural: 40.0%, p=0.008). However, survival analysis did not demonstrate significant differences in estimated mean postoperative survival between groups (urban: 9.19 years vs. rural: 9.87 years, p=0.162; local: 9.15 years vs. non-local: 9.72 years, p=0.219). <h3>Conclusions</h3> At the national level, four Canadian VQI centres demonstrated higher rates of loss to follow-up and decreased one-year survival among patients from rural communities. In contrast, a subgroup analysis from our institution revealed that rural and non-local patients received fewer follow-up appointments and underwent less postoperative imaging; however, no significant differences in mortality or reintervention were observed. The influence of geographic distance and rurality status on follow-up and imaging highlights a potential vulnerability to aneurysm-related mortality, warranting further investigation.