Sex-Related Mortality After Abdominal Aortic Aneurysm Surgery

Study Questions:

Do trends in mortality among abdominal aortic aneurysm (AAA) surgery patients differ by sex?


Elective AAA surgeries performed at National Health Service hospitals in England between April 2002 and March 2013 (for open repair) and between January 2006 and March 2013 (for endovascular repair) were included in this analysis. Patients were identified through a review of the Hospital Episode Statistics and Office for National Statistics data sets. The primary outcome of interest was 30-day mortality. Secondary outcomes included mortality at 1 and 5 years, aortic-related mortality, and postoperative complication rates.


A total 31,090 patients (4,795 women and 26,295 men) underwent open AAA repair, and 16,777 patients (2,036 women and 14,741 men) underwent endovascular aneurysm repair (EVAR). Among patients undergoing open repair, women were older and more likely to have congestive heart failure, chronic obstructive pulmonary disease (COPD), rheumatological conditions, and hemiplegia or paraplegia, while men were more likely to have cardiovascular disease (CVD) risk factors (prior myocardial infarction, diabetes mellitus, and peripheral vascular disease). The total numbers of comorbidities in the Royal College of Surgeons’ Charlson score (absolute score) were not statistically significant between women and men. Characteristics were similar in the EVAR group, with women being older and more likely to have COPD and rheumatological conditions as well as dementia, but with less CVD risk factors than men. In the EVAR group, women were more likely to have Royal College of Surgeons’ Charlson score greater than zero, as compared with men. All-cause and aortic-related mortalities at 30 days, 1 year, and 5 years were higher in women, despite a lower prevalence of preoperative CV risk factors. Female sex was a significant independent risk factor for 30-day mortality in both open repair (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.25-1.56; p < 0.001) and EVAR (OR, 1.57; 95% CI, 1.23-2.00) groups. The estimated hazard for women in the open repair group was significantly (p = 0.006) higher than men. In contrast, the difference between women and men was not significant in the EVAR group (p = 0.356). In the open repair group, women had significantly higher cumulative incidence probabilities for both aortic-related mortality and other-cause mortality. In the EVAR group, women had significantly higher mean cumulative incidence probabilities for the aortic-related mortality compared with men, but not for the other-cause mortality.


The investigators concluded that women undergoing elective AAA repair at National Health Service hospitals in England had increased short- and long-term mortality and postoperative morbidity compared with men. These findings can be used to improve preoperative counseling for women undergoing AAA repair, and highlight the need for female-specific pre-, peri-, and postoperative management strategies.


These data highlight the need to understand surgical outcomes among women. Sex should be a key biologic variable to be assessed in health services research related to surgical outcomes.

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