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Endovascular Repair Suitability, Nonintervention Rates, and Operative Mortality in AAA
Study Questions:
What are the differences in outcomes between men and women being assessed for repair of abdominal aortic aneurysm (AAA)?
Methods:
This systematic review with meta-analysis was based on randomized, cohort, and cross-sectional studies published after 2000 that assessed AAA for repair by either endovascular repair (EVAR) or open repair. Selected studies included both men and women and presented sex-specific data separately for both. EVAR suitability (based on manufacturer’s instructions for use), nonintervention, and operative mortality were reviewed. The Newcastle-Ottawa system was used to assess study quality, and random-effects meta-analysis was used to combine results across studies.
Results:
Five studies of EVAR suitability in 1,507 men and 400 women found that the proportion of women eligible was lower than for men (34% vs. 54%; odds ratio [OR], 0.44; 95% confidence interval [CI], 0.32-62). Four studies (1,365 men and 247 women) reported higher nonintervention rates in women than men (34% vs. 19%; OR, 2.27; 95% CI, 1.21-4.23). Nine studies (52,018 men and 11,076 women) reported higher perioperative mortality for women than men for both EVAR (2.3% vs. 1.4%; OR, 1.67; 95% CI, 1.38-2.04) and open repair (5.4% vs. 2.8%; OR, 1.76; 95% CI, 1.35-2.30).
Conclusions:
Compared to men, women with AAA have a lower rate of EVAR eligibility and are less likely to be offered intervention. Operative mortality is higher in women for both EVAR and open repair. AAA treatment in women needs improvement.
Perspective:
Study selection bias, reporting bias, and design issues related to gender-specific outcomes continue to limit evidence-based treatment of AAA in women. Meta-analytic methods used in this study overcome some of these limitations to provide a snapshot of just a few of the disparities faced by women with AAA, who are less often candidates for EVAR, less likely to be offered intervention, and more likely to die within 30 days of either EVAR or open repair.
The decreased rates of morphological eligibility for EVAR in women might be expected to go along with higher nonintervention rates. Patients may be less inclined to accept open repair, which is higher risk and more invasive. As EVAR technology improves and advances, morphological eligibility is a moving target that is increasingly inclusive. Corresponding declines in rates of open repair (which is increasingly reserved for complex anatomy or conversion after failed EVAR) are particularly high impact for women with AAA, who rely on a shrinking pool of surgeons with adequate open repair volume and experience to take on complex cases.
Improved AAA treatment for women will require a joint effort from clinicians, researchers, and device manufacturers. The growing demand for gender-specific outcomes reporting from publishers and research funding organizations is a step in the right direction that will hopefully be followed by development (and widespread availability) of EVAR technology suited to women’s unique anatomy. Women with AAA deserve the same options and access to repair enjoyed by men, and elimination of these gender disparities deserves focused attention and strong support.
Keywords: Aortic Aneurysm, Abdominal, Cardiac Imaging Techniques, Cardiac Surgical Procedures, Endovascular Procedures, Mortality, Perioperative Period, Treatment Outcome, Vascular Diseases, Surgical Procedures, Operative
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