Barriers and Facilitators to Endovascular Aortic Repair Follow-Up.

Importance: The rate of follow-up after endovascular aortic repair (EVAR) of an abdominal aortic aneurysm (AAA) is low despite guidelines recommending regular surveillance due to increased risk of stent-related complications, rupture, and death. Objective: To identify existing barriers and facilitators to patient follow-up adherence after EVAR to inform future interventions to improve follow-up adherence. Design, Setting, and Participants: This qualitative study used purposive diversity sampling in a multisite, academic health system to interview patients who underwent elective or emergency EVAR between October 2019 and October 2021 and had varying follow-up patterns; health care professionals (HCPs), including vascular surgeons and advanced practice providers ([APPs] nurse practitioners and physician associates); and key clinical personnel, including administrative assistants, schedulers, nurses, and medical assistants with diverse backgrounds and experience with EVAR. Data were collected between December 2021 and February 2023. Data were analyzed between December 2022 and April 2025. Exposure: Participants engaged in a single semistructured phone interview. Interview guides and thematic analysis were informed by the Theoretical Domains Framework. Main Outcomes and Measures: Barriers and facilitators to patient follow-up adherence after EVAR. Results: The sample included 55 participants (25 patients [17 (68%) males], 16 HCPs [12 physicians and 4 APPs], and 14 key clinical personnel). Of the patients, 13 had complete follow-up and a median (IQR) age of 71.6 (63.8-75.6) years, and 12 had incomplete follow-up and a median (IQR) age of 72.0 (66.3-79.3) years. The HCPs had a median (range) 7 (3-16) years in practice, and key clinical personnel worked in their current position a median (range) 2 (1-4) years. Four main themes were identified during the qualitative analysis. In theme 1, patients' perceptions of follow-up importance were primarily affected by beliefs about immediate consequences and physical reinforcements (ie, symptoms). In theme 2, despite attempts by HCPs to provide education, patients' knowledge of anatomical concepts did not translate to better follow-up; however, explicit knowledge of clinical consequences (ie, rupture and death) did. In theme 3, patient memory and attention issues posed barriers to follow-up, but these barriers were partially mitigated by protocolization of follow-up processes (eg, appointment reminders, standardization of preoperative and postoperative resources, and optimization of discharge paperwork). In theme 4, social support and environmental circumstances, particularly transportation, were both substantial facilitators and barriers to follow-up. Conclusions and Relevance: In this qualitative study, patient focus on immediate outcomes after EVAR and memory and attention factors were important barriers to follow-up. However, recognition of explicit long-term consequences, presence of social support, and protocolization facilitated follow-up. Potential interventions to improve follow-up could include enhanced protocolization, a robust recall system to identify and contact patients with missed appointments, careful expansion of telemedicine, and transportation adjuncts.