Women undergoing endovascular thoracoabdominal aortic aneurysm repair differ significantly from their male counterparts preoperatively and postoperatively

Abstract

Objective: A rational approach to the management of aortic aneurysm disease relies on weighing the risk of aneurysm rupture against the complications and durability of operative repair. In men, seminal studies of infrarenal aortic aneurysm disease and its endovascular management can provide a reasoned argument for the timing and modality of surgery, which is then extrapolated to the management of thoracoabdominal aortic aneurysms (TAAAs). In contrast, there is less appreciation for the natural history of TAAA disease in women and its response to therapy.Methods: We used a retrospective cohort design of women, all men, and matched men, fit for complex endovascular thoracoabdominal aneurysm repair at two large aortic centers. We controlled for preoperative anatomic and comorbidity differences, and assessed technical success, postoperative renal dysfunction, spinal ischemia, and early mortality. Women and matched men were reassessed at follow-up for long-term durability and survival.Results: Assessing women and all men undergoing complex endovascular aortic reconstruction, we demonstrate that these groups are dissimilar before the intervention with respect to comorbidities, aneurysm extent, and aneurysm size; women have a higher proportion of proximal Crawford extent 1, 2, and 3 aneurysms. Matching men and women for demographic and anatomic differences, we find persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aneurysm repair compared with matched men (6%); however, at the 3-year follow-up, both groups have the same survival. Furthermore, women demonstrate more favorable anatomic responses to aneurysm exclusion, with good durability and greater aneurysm sac regression at follow-up, compared with matched men.Conclusions: Women and unmatched men with TAAA disease differ preoperatively with respect to aneurysm extent and comorbidities. Controlling for these differences, after complex endovascular aneurysm repair, there is increased early mortality in women compared with matched men. These observations argue for a careful risk stratification of women undergoing endovascular thoracoabdominal aneurysm treatment, balanced with women's good long-term survival and durability of endovascular aneurysm repair.

Influence of sex after elective thoracic endovascular aortic repair

“…The lower early mortality is possible with suitable anatomy, team experience, and device improvements over time. [13,16] Complicated aortic or vessel anatomy, worse baseline health and more symptomatic aneurysms may be possible reasons. In our study, symptomatic patients were numerically higher in female group than the male group (52.2% vs. 41.3%, respectively); however, there were no significant differences in the baseline demographics.…”

Sex-Related Anatomical Feasibility Differences in Endovascular Repair of Thoracoabdominal Aortic Aneurysms With a Multibranched Stent-Graft

“…20,21 Analyzing 959 patients (163 women), Rieß et al 21 found female patients to be at higher risk of in-hospital mortality (OR 3.21, p<0.001), to have lower long-term survival (hazard ratio 1.51, p=0.006), and to be associated with more complications, including acute renal failure [relative risk (RR) 1.71, 95% CI 1.06 to 2.77], paraplegia (RR 2.71, 95% CI 1.28 to 5.77), and bleeding requiring transfusion (RR 1.76, 95% CI 1.39 to 2.22). Withefort et al 20 also found women to have a higher proportion of Crawford extent I, II, and III aneurysms and higher perioperative mortality (16% vs 6%), with similar survival at 3 years. In contrast to earlier studies, they also demonstrated that women tend to have a more favorable response to endovascular aneurysm exclusion, with satisfying durability and greater aneurysm sac regression compared with a matched cohort of male patients.…”

“…17,18 A recent systematic review assessed the anatomical feasibility of commercially available AAA stent-grafts, demonstrating that they are primarily designed for the male anatomy. 19 Two recent studies compared sex differences in thoracoabdominal aortic aneurysm (TAAA) patients treated by means of fenestrated/branched endovascular aortic repair (f/bEVAR), 20,21 but no research has yet investigated the sex differences in potential TAAA treatment with off-the-shelf stent-grafts.…”

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

“…Female sex in the American College of Surgeons National Surgical Quality Improvement Program (1,010 open repair -30.7% females and 1,260 EVARs -21.4% females) is associated with higher perioperative mortality and more major complications than for male pts after complex EVAR (juxtarenal, pararenal, or suprarenal) but not after complex open repair [140]. Also, women have a persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aortic aneurysm (TAAA) repair compared with matched men (6%) due to differences in comorbidities, aneurysm extent, and aneurysm size [141]. Worse in-hospital and long-term survival compared to males may also relate to the impact of anatomy on outcome disparities [142].…”