Women Derive Less Benefit From Elective Endovascular Aneurysm Repair Than Men

Study Questions:

Do women derive the same survival benefit from elective endovascular aortic aneurysm repair (EVAR) as men?

Methods:

This was a retrospective analysis of a prospectively maintained database containing 2,631 elective and emergent abdominal aortic aneurysm repairs (both open aortic repair and EVAR) performed at a single center from 2002 to 2009. Primary outcomes were operative blood loss, incidence of type I endoleak, length of in-hospital stay, postoperative complications, 30-day all-cause mortality, and secondary interventions performed in the follow-up period.

Results:

Of the 2,631 abdominal aortic aneurysms repaired, 1,698 (106 emergent) were EVAR and 933 (149 emergent) were open surgical repairs. Women comprised 24% of the total study patients. For women, elective EVAR resulted in significantly greater mortality rates in men (3.2% vs. 0.96%, p < 0.05), and women experienced a higher incidence of intraoperative aortic neck or iliac artery rupture (4.1% vs. 1.2%, p = 0.002) as well as higher use of Palmaz stents for type I endoleaks (16.1% vs. 8%, p = 0.0009). Mean blood loss, and rates of postoperative leg and colon ischemia requiring colectomy, were significantly higher in women compared with men undergoing elective EVAR. There was no significant difference in death rates between EVAR and open repair in women (3.2% vs. 5.7%). Logistic regression revealed that female gender was a significant risk factor, with an odds ratio of 3.4 (p < 0.01).

Conclusions:

The authors concluded that women derive less benefit from elective endovascular repair compared to men. Women have higher rates of mortality, colon ischemia, arterial rupture, and type I endoleaks than men undergoing elective EVAR.

Perspective:

This study suggests that women do not see the early (30-day) survival advantage associated with elective EVAR as do men. Moreover, mortality rates in women were similar to men for emergent EVAR, elective open surgical repair, and emergent open surgical repair. These observations, combined with the observed higher incidence of native arterial rupture and type I endoleaks, suggest that the difference in elective EVAR mortality between genders might be due to more hazardous female aortic anatomy. If this is the case, I would expect women to benefit more than men with the development of more flexible and smaller profile endograft delivery devices. These devices should accommodate the smaller, more tortuous iliacs and angulated infrarenal necks that are more often seen in women undergoing elective EVAR.

Clinical Topics: Vascular Medicine

Keywords: Surgical Procedures, Elective, Aortic Aneurysm, Abdominal


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