Gender Differences in Abdominal Aortic Aneurysm Presentation, Repair, and Mortality in the Vascular Study Group of New England

Study Questions:

Do outcomes related to abdominal aortic aneurysm (AAA) repair, in particular endovascular aneurysm repair (EVAR), differ by gender?

Methods:

This was a retrospective review of open and endovascular AAA repairs from the Vascular Study Group of New England database, a voluntary collaboration among vascular surgeons, cardiologists, and radiologists from 30 academic and community hospitals in the six New England states. Data on vascular procedures collected since 2003 included detailed perioperative and procedural information, and longitudinal outcomes are available at 1 year. Patients undergoing EVAR or open AAA repair between 2003 and 2011, were identified, and categorized by presentation as intact (including patients who were symptomatic as well as those undergoing elective repair) or ruptured. Four subgroup analyses were performed: intact EVAR, ruptured EVAR, intact open repair, and ruptured open repair.

Results:

A total of 4,026 patients (78% men) who underwent AAA repair (54% EVAR) were identified. Rupture was the presenting indication for repair in 11% of men and 9% of women. Women undergoing intact repair were 3 years older than men (median age, 75 vs. 72 years; p < 0.001), whereas those undergoing rupture repair were 5 years older (median age, 78 vs. 73 years; p < 0.001). As a proportion of all repairs, use of EVAR increased from 40% in 2003 to 73% in 2011. Men were more likely to undergo EVAR than open repair for intact repairs (60% EVAR for men vs. 50% EVAR for women; p < 0.001), but not ruptured repairs (20% EVAR for men vs. 26% EVAR for women; p = 0.234). Women had smaller aortic diameters than men for intact (57 vs. 59; p < 0.001) and ruptured (71 vs. 78 mm; p < 0.001) aneurysms. Arterial injury was more common in women (5.4% vs. 2.7%; p = 0.013) among patients undergoing EVAR for intact aneurysms. Women stayed in the hospital longer (4.3 vs. 2.7 days; p = 0.018) and had lower odds of being discharged home, even after adjusting for age. Among patients undergoing open repair for intact aneurysms, women more frequently experienced leg ischemia/emboli (4% vs. 1%; p = 0.001) and bowel ischemia (5% vs. 3%; p = 0.044). Women had higher 30-day mortality after open aneurysm repair for intact (4% vs. 2%; p = 0.03) and rupture (48% vs. 34%; p = 0.03) repairs. However, 30-day mortality after EVAR was similar for intact (1% in men vs. 1% in women; p = 0.57) and rupture (29% in men vs. 27% in women; p > 0.99) repairs. Late survival was worse in women than men only for patients undergoing open repair of ruptured aneurysms (hazard ratio, 1.8; 95% confidence interval, 1.0-3.1; p = 0.04). After controlling for age, type of repair, urgency at presentation (i.e., elective/intact vs. ruptured), comorbidities, and other relevant risk factors, gender was not predictive of 30-day or 1-year mortality.

Conclusions:

The investigators concluded that women with AAAs are being treated at older ages and smaller AAA diameters, and are undergoing rupture repair at smaller diameters than men. Women are more likely to experience perioperative complications as a result of less favorable vascular anatomy. Age >80 years, comorbidity, presentation, and type of repair are more important predictors of mortality than gender.

Perspective:

These data provide both clinicians and their patients with valuable information on risks associated with aneurysm repair. Although women experience more complications compared to men, it appears that comorbidities and other risk factors account for this increased risk, rather than gender.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Aortic Surgery, Interventions and Vascular Medicine

Keywords: Cooperative Behavior, Blood Vessel Prosthesis Implantation, Surgical Procedures, Elective, Aneurysm, Ruptured, Hospitals, Community, Comorbidity, Risk Factors, Confidence Intervals, Aortic Aneurysm, Abdominal, New England


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