Impact of Gender on Outcomes Following Abdominal Aortic Aneurysm Repair

Abstract

Objective: The purpose of this study is to use a large, nationally representative vascular database to assess differences in patient characteristics, aortic neck anatomy, and outcomes between men and women following open (open aneurysm repair [OAR]) and endovascular (endovascular aneurysm repair [EVAR]) abdominal aortic aneurysm (AAA) repair. Methods: Patients undergoing AAA repair from 2003 to 2018 in Vascular Quality Initiative were identified and stratified by procedure (EVAR vs OAR). Thirty-day mortality and major in-hospital complications were assessed between genders within each operative cohort. An EVAR subset analysis was performed to assess differences in aortic neck anatomy; hostile neck anatomy was defined as length <15 mm (L < 15), angle >60° (A > 60), and/or diameter >28 mm (D > 28). Standard univariate and multivariable analyses were performed. Results: A total of 50 213 patients were identified: 9263 (19%) OAR and 40 950 (82%) EVAR. In both cohorts, majority of patients were men (OAR 73% and EVAR 81%). Women were more likely to have a hostile neck (31.7% vs 24.1%, P < .001), L < 15 (19.8% vs 11.9%, P < .001), and A > 60 (11.5% vs 5.4%, P < .001). Men had larger aneurysm (mean, 57 vs 55 mm, P < .001) and were more likely to have D > 28 (14.0% vs 10.6%, P < .001). Women undergoing EVAR were more likely to undergo aortic extensions (21.9% vs 16.0%) and receive higher contrast volume. After adjusting for potential confounders, female gender was associated with 86% and 50% increased risk of 30-day mortality in OAR and EVAR, respectively. Women were more likely than men to experience renal, cardiac, and pulmonary complications only in the EVAR cohort. Women had a 2-fold increased odds of developing type 1 endoleak. Conclusion: Our study demonstrates unfavorable neck anatomy occurs more frequently in women compared to men. Women were also at an increased risk of developing major complications, particularly following EVAR. Careful patient selection is indicated in all patients to reduce complications, with special attention in women with hostile neck.

Editor's Choice – Systematic Review and Meta-Analysis of Sex Specific Differences in Adverse Events After Open and Endovascular Intact Abdominal Aortic Aneurysm Repair: Consistently Worse Outcomes for Women

“…56,57 Sex specific differences in kidney injury may also result from embolism, anatomical differences (e.g., closer proximity of the renal arteries, orificial disease, angulation), selection of suboptimal endovascular strategies (e.g., renal artery coverage), or iatrogenic injury (e.g., contrast nephropathy or intimal damage). 39,58 Renal protective strategies such as pre-hydration, avoidance of renotoxic medication, judicious use of contrast, and a careful operative approach with renal preservation, can greatly reduce the risk of renal injury and should be strictly implemented for women. 58,59 EVAR access complications are associated with four times the odds of peri-operative death, while conversion to open, rather than planned cutdown, is associated with a higher risk of major complication.…”

“…3). 7,25,36,38,39 An increased risk of arterial injury for women undergoing EVAR was also observed (OR 3.02 [1.62 e 5.65], p < .001, I 2 ¼ 49). 4,19,33,36 Operative time (minutes) was statistically significantly lower for women compared with men for OAR (MD À14.98 [À18.45 e À11.51], p < .001, I 2 ¼ 0), and not statistically significantly different for EVAR (MD 4.33 [À0.99 e 9.65], p ¼ .11, I 2 ¼ 79) (Supplementary Table S4).…”

“…4,7,25,33,38e40 On average, women spent longer in intensive care compared with men following OAR (MD 0.93 [0.65 e 1.21], p < .001, I 2 ¼ 31, days), but not for EVAR. 3,7,33,41 An increased length of 3,7,9,19,25,33,38,39,41,43 Meta-regression to assess the influence of sex specific differences in post-operative complications on between study heterogeneity for mortality outcomes was limited by paucity of data. For OAR, insufficient data reporting prevented any evaluations.…”

Investigation of Renal Decline and New Onset Dialysis Following Endovascular Aneurysm Repair in the Vascular Quality Initiative

“…For example, women present for repair at a slightly advanced mean age relative to men, 18 are more likely to have smaller diameter arteries, 19 and are more likely to have a hostile neck. 20 Females on average have less renal parenchymal volume and thus the effect of the same contrast, devices and manipulation near the renal artery orifices is more impactful. Baseline renal insufficiency was a significant harbinger of ARI (OR 2.28), long-term renal decline (HR 1.31) and new onset dialysis requirement (OR 6.33) after EVAR.…”

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

“…This disparity might be explained by the higher peri-operative mortality in women undergoing open surgery, because no such difference was found in pts undergoing EVAR [131]. In contrast, Locham et al found in the Vascular Quality Initiative (2013-2018, 9,263 open surgery -73% men and 40,950 EVAR -81% men), that unfavorable neck anatomy occurs more frequently in women compared to men [132]. Women were also at an increased risk of developing major complications, particularly following EVAR, received more aortic extensions and more contrast volume.…”