Sex-specific differences in the standard of care for infrarenal abdominal aortic aneurysm repair, and risk of major adverse cardiovascular events and death

Abstract

Background This study investigated whether sex-specific differences in preoperative/perioperative standard of care (SOC) account for disparity in outcomes after elective infrarenal abdominal aortic aneurysm repair. Methods This was a retrospective cohort study of elective infrarenal abdominal aortic aneurysm repairs (2013–2020) using depersonalized patient-level National Vascular Registry data. SOC was defined for waiting times, preoperative assessment (multidisciplinary/anaesthetic review), cardiovascular risk prevention, and perioperative medication. The primary outcome was major cardiovascular event and/or death (MACED). Results Some 21 810 patients with an infrarenal abdominal aortic aneurysm were included, 2380 women and 19 430 men. Women less often underwent aneurysm repair within SOC waiting times (51.5 versus 59.3 per cent; P < 0.001), but were equally likely to receive preoperative assessment (72.1 versus 72.5 per cent; P = 0.742). Women were less likely to receive secondary prevention for known cardiac disease (34.9 versus 39.6 per cent; P = 0.015), but more often met overall cardiovascular risk prevention standards (52.1 versus 47.3 per cent; P < 0.001). Women were at greater risk of MACED (open: 12.0 versus 8.9 per cent, P < 0.001; endovascular: 4.9 versus 2.9 per cent, P < 0.001; risk-adjusted OR 1.33, 95 per cent c.i. 1.12 to 1.59). A significant reduction in the odds of MACED was associated with preoperative assessment (OR 0.86, 0.75 to 0.98) and SOC waiting times (OR 0.78, 0.69 to 0.87). There was insufficient evidence to confirm a significant sex-specific difference in the effect of SOC preoperative assessment (women: OR 0.69, 0.50 to 0.97; men: OR 0.89, 0.77 to 1.03; interaction P = 0.170) or SOC waiting times (women: OR 0.84, 0.62 to 1.16; men: OR 0.76, 0.67 to 0.87; interaction P = 0.570) on the risk of MACED. Conclusion SOC waiting times and preoperative assessment were not met for both sexes, which was associated with an increased risk of MACED. Sex-specific differences in SOC attenuated but did not fully account for the increased risk of MACED in women.

Exploring the gender gap in surgical outcomes

“…3,4 Previous meta-analysis investigating gender differences in vascular surgery reported that women had an equal if not higher prevalence of peripheral arterial disease (PAD), more severe disease at presentation and often have poorer outcomes. 5 Do the present data dispel or propagate the gender gap in healthcare? At first glance, these data could be regarded as cause for optimism and an absence of any differential outcomes in these Swedish vascular patients.…”

“…Within cardiovascular surgery, women have been shown regularly to have poorer outcomes; notably after coronary artery surgery and aortic aneurysm repair 3,4 . Previous meta‐analysis investigating gender differences in vascular surgery reported that women had an equal if not higher prevalence of peripheral arterial disease (PAD), more severe disease at presentation and often have poorer outcomes 5 …”