Editor's Choice – Sex Specific Differences in the Management of Descending Thoracic Aortic Aneurysms: Systematic Review with Meta-Analysis

Abstract

WHAT THIS PAPER ADDS Thirty day mortality after thoracic endovascular aneurysm repair for descending thoracic aortic aneurysm is almost twice as high in women as in men, and women have a slightly longer hospital stay. These facts are similar to previous results from systematic reviews of lower limb revascularisation and abdominal aortic aneurysm repair. The reasons for these sex specific differences need to be identified urgently, with a view to their correction. For open repair, there are insufficient recent data to address sex specific differences in outcomes. Objectives: To assess sex specific differences in 30 day mortality, length of hospital stay, and adverse neurological events following repair of intact degenerative descending thoracic aortic aneurysms (TAAs), by either thoracic endovascular (TEVAR) or open repair. Methods: MEDLINE, Embase, and CENTRAL databases were searched from 2005 to 2019, using ProQuest Dialog. The reviews were registered in PROSPERO (CRD42017020026) and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome was 30 day mortality; secondary outcomes were length of hospital stay and adverse neurological events. Forest plots with random effects meta-analysis to provide odds ratios (OR) were used for primary assessment. Results: For TEVAR, seven studies were identified, including 2758 women and 4674 men; of these studies six were eligible for the primary outcome of 30 day mortality, including 1756 women and 2619 men. There were 94/1756 deaths in women and 82/2619 deaths in men, yielding a pooled 30 day mortality of 5% (95% confidence interval [CI] 3e7) in women and 3% (95% CI 2e4) in men (OR 1.75, 95% CI 1.29e2.38). Length of hospital stay was longer in women, with a standardised mean difference of 0.3 days (95% CI 0.14e0.47; six studies): meta-regression analysis did not identify the slightly older age of women as significant factor in these differences. Stroke rate was not different between the sexes. For open repair only a single study, with national coverage, was identified: this study reported similar 30 day mortality in men and women. Conclusions: In the management of intact degenerative descending TAAs, 30 day mortality after TEVAR appears to be much higher in women than men with no reasons for this difference identified. However, for open repair there is a lack of contemporary evidence owing to insufficient recent data.

Sex differences and temporal trends in aortic dissection: a population-based study of incidence, treatment strategies, and outcome in Swedish patients during 15 years

“… 18 , 19 A recent meta-analysis of sex-specific differences in association with repair of descending thoracic aortic aneurysms identified higher 30-day mortality in women, a finding unrelated to age. 20 Any possible biological sex differences in eligibility for repair of the thoracic aorta and the reason behind the sex-specific mortality differences remain to be identified.…”

“… 2 , 9–12 Postoperative mortality after TEVAR for descending thoracic aortic aneurysm has been reported to be higher in women. 20 The same review conclude that the reason for the sex differences in mortality is unknown but speculates that sex differences in aortic morphology and hidden coronary heart disease in women are possible reasons. 20 Another possible explanation to the sex differences in mortality could be that clinicians fail to adhere to guidelines when treating women, as reported for coronary heart disease and abdominal aortic aneurysms.…”

“… 20 The same review conclude that the reason for the sex differences in mortality is unknown but speculates that sex differences in aortic morphology and hidden coronary heart disease in women are possible reasons. 20 Another possible explanation to the sex differences in mortality could be that clinicians fail to adhere to guidelines when treating women, as reported for coronary heart disease and abdominal aortic aneurysms. 18 , 19 Our results show higher 30-day mortality in medically managed patients compared to acute surgically treated patients (27% vs. 14%).…”

Influence of sex after elective thoracic endovascular aortic repair

“…Sex differences in outcomes after vascular surgery exist and have been well studied. [3][4][5][6][7][8][9][10][11][12][13] There are differences between sexes at every stage of the disease, from epidemiology to pathophysiology and from morbidity to mortality. [1,8,11] Females usually present with smaller aneurysms along with greater growth rates and rupture risk.…”

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

“…In a meta-analysis of 7 studies from 2005-2019 for the management of intact descending aortic aneurysms, analysis of 2,758 women and 4,674 men demonstrated that 30 day mortality after TEVAR appears to be much higher in women than men with no reasons for this difference identified [143].…”