The association of rural residence with aneurysm presentation and loss to follow-up after endovascular aneurysm repair in the Vascular Quality Initiative.

OBJECTIVE: Early recognition, timely access to care, and diligent follow-up are essential components of care for patients with aortic aneurysms. Rural patients have significant barriers to care and may present for surgery with larger aneurysms and be more likely to be lost to follow-up (LTFU). The purpose of this study was to assess the effects of rurality on clinical presentation of abdominal aortic aneurysms (AAA) and follow-up after EVAR. METHODS: The Vascular Quality Initiative (VQI) U.S. EVAR module (2003-2021) was used for analyses (n=62,503). Patients were categorized as residing in an urban or rural area using Rural-Urban Commuting Area (RUCA) codes. Univariate analyses were performed to describe differences in sociodemographic, intraoperative, and follow-up factors. We fit unadjusted and adjusted logistic regression models to assess the association between rurality and aneurysm size, symptomatic presentation, adverse cardiovascular events, death, loss to follow-up, and follow-up type. RESULTS: Seventy-nine percent (n=49,372) of patients were classified as urban and 21% (n=13,131) as rural with several significantly different demographic variables. On multivariable analyses, residing in a rural compared to urban area was significantly associated with 9% higher odds of undergoing repair with an aneurysm diameter of > 6.5 cm (aOR: 1.09, 95% CI: 1.03-1.15), an 18% increase in the odds of presenting with an urgent AAA compared to elective (aOR: 1.18, 95% CI: 1.11-1.24) and a 14% increase in the odds of being LTFU (aOR: 1.14, 95% CI: 1.05-1.23). Finally, of the patients that did follow-up, rural compared to urban residence was associated with a 10% lower odds of having in-person follow-up (aOR: 0.90, 95% CI: 0.86-0.95), but was associated with 13% higher odds of having any follow-up imaging (aOR: 1.13, 95% CI: 1.04-1.23). CONCLUSIONS: This study found that rural patients had higher odds of large aneurysms at time of repair, higher odds of requiring urgent repair, and being LTFU. When they did have follow-up, it was less likely to be in person. This suggests geographic disparities in quality of and access to appropriate AAA screening, repair and follow-up. Addressing this disparity will require coordinated multidisciplinary efforts, efficient referral pipelines, and reliable surveillance mechanisms post-operatively. Future efforts should aim to develop and implement evidence-based care delivery strategies for AAA care for patients in rural settings, such as primary care clinician education, telehealth platforms and travel assistance.