Debate: Whether evidence supports reducing the threshold diameter to 5 cm for elective interventions in women with abdominal aortic aneurysms

Abstract

Current practice guidelines recommend repair of asymptomatic abdominal aortic aneurysms once they reach the 5.5-cm-diameter threshold and are based on information from randomized controlled trials. However, because aneurysms are more common in men, women are under-represented in these trials, and questions persist about whether this repair threshold should apply to them. In addition, women have smaller aortas to begin with and in most aneurysm cohorts are older, have more atherosclerotic risk factors, are less likely to be anatomic candidates for endovascular repair, and do poorer after emergency or elective repair of their aneurysm. These are just some of the issues that our discussants address in determining whether the repair threshold should be at a smaller diameter for women.

Reconsidering gender relative to risk of rupture in the contemporary management of abdominal aortic aneurysms

“…Although timely diagnosis and elective vascular surgical intervention before AAA rupture are the best means of reducing AAA mortality, the size threshold at which this goal can be optimally achieved is a subject of much interest. [5][6][7] Maximum AAA diameter is widely accepted as the best predictor of rupture, but its proper measurement by external diameter, centerline axial reconstruction, or aortic indexing is a matter of practical and investigational concern beyond the scope of this study. 1,8,9 Current practice guidelines endorsed by the SVS recommend observation of asymptomatic AAAs <5.5 cm in diameter, 3 but this recommendation is gender neutral and therefore presumes that the same risks of aneurysm rupture and mortality apply equally to both sexes.…”

“…2,15,16 This study confirmed that women with AAAs were older than their male counterparts and had a higher frequency of risk factors associated with increased AAA mortality as previously reported. 2,6,17,18 It has been previously suggested that women are often at higher operative risk because of age and comorbidities, 5,12,16,19 and the female gender has been recognized as an independent risk factor for AAA rupture. 1,[20][21][22] These data indicate a trend toward increased postoperative mortality in women, but the differences were not statistically significant.…”

Ultrasound screening for abdominal aortic aneurysm in high-risk women

“…In individuals affected, AAA represents a greater risk for women than for men. As a result, the question has arisen whether women are disadvantaged by the current screening models, which exclude them from established AAA screening programmes 3 , 9 , 11 .…”