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Association of Sex With AAA Repair and Long-Term Mortality
Study Questions:
What is the association between sex with repair type and long-term mortality in adults with abdominal aortic aneurysm (AAA)?
Methods:
The investigators conducted a retrospective cohort study using data from the Vascular Quality Initiative, a national clinical registry, and Medicare claims to investigate endovascular and surgical repair procedures performed between January 1, 2003, and September 30, 2015, in patients aged ≥65 years with AAA. The data were analyzed from October 1, 2018, to November 19, 2019. The main outcome measure was endovascular (EVR) or open surgical AAA repair type and subsequent long-term, all-cause mortality. The primary exposure was sex, and men served as the reference group. Authors used logistic regression to study sex-based differences based on the AAA repair type, with EVR repair serving as the reference treatment. Sex-based differences in long-term mortality were evaluated using Kaplan-Meier survival analysis, log-rank test, and Cox regression.
Results:
In this cohort study of 16,386 patients, 12,757 (77.9%) were men and 3,629 (22.1%) were women. Women were more likely than men to be older (mean [standard deviation] age, 77 [6.5] years vs. 75 [6.6] years; p < 0.001), active smokers (33% vs. 28%; p < 0.001), and to have smaller aneurysms (mean [standard deviation] diameter, 57 [11.7] mm vs. 59 [17.7] mm; p < 0.001). Surgical AAA repair was performed in 27% (983 of 3,629) of women compared with 18% (2,328 of 12,757) of men (p < 0.001). After inverse probability weighting for risk adjustment, women were more likely to receive open surgical repair than EVR repair (risk ratio, 1.65; 95% confidence interval [CI], 1.51-1.80). The 10-year unadjusted survival rate after EVR repair was 14% lower in women than in men (23% vs. 37%; log-rank p < 0.001), but the rates were comparable after open surgical repair (36% in men vs. 32% in women; log-rank p = 0.22). Risk-adjusted analysis showed that women were associated with higher mortality rates after EVR repair (hazard ratio, 1.13; 95% CI, 1.03-1.24), whereas both men and women had a similar risk of death after open surgical repair (hazard ratio, 0.94; 95% CI, 0.84-1.06). After further stratification by symptom severity, higher risk of mortality among women was limited to elective EVR and open surgical repair for ruptured AAA.
Conclusions:
The authors concluded that women were 65% more likely than men to undergo open surgical repair and women were 13% more likely to die than men after EVR repair, although no sex-based difference in mortality was found after open surgical repair.
Perspective:
This cohort study reports that women were 65% more likely than men to undergo open surgical repair than EVR repair and had lower rates of 10-year postoperative survival, even after risk adjustment. The sex difference in mortality was primarily associated with EVR procedures and open surgical treatment for ruptured AAAs. Overall, these data suggest that women have decreased survival benefit with AAA repair, especially after EVR repair, which is worrying given the shift toward an EVR-first approach to AAA management. Understanding sex-based differences in AAA treatment strategy choice and mortality using real-world data will be key to developing AAA management strategies that offer the greatest benefit of AAA repair to both men and women with tailored strategies for each patient.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine, Smoking
Keywords: Aortic Aneurysm, Abdominal, Cardiac Surgical Procedures, Endovascular Procedures, Geriatrics, Outcome Assessment, Health Care, Risk Adjustment, Secondary Prevention, Smoking, Survival Analysis, Vascular Diseases, Women
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