Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England

Abstract

Objective: Prior studies of gender differences in abdominal aortic aneurysm (AAA) repair suggest there may be differences in presentation, suitability for endovascular aneurysm repair (EVAR), and outcomes between men and women.

Methods: We used the Vascular Study Group of New England database to identify all patients undergoing EVAR or open AAA repair. We analyzed demographics, comorbidities, and procedural, and perioperative data. Results were compared using the Fisher exact test and the Student t-test. Multivariable logistic regression and Cox proportional hazards modeling were performed to identify predictors of mortality.

Results: We identified 4026 patients (78% men) who underwent AAA repair (54% EVAR). Women were less likely than men to undergo EVAR for intact aneurysms (50% vs 60% of intact AAA repair; P < .001) but not for ruptured aneurysms (26% vs 20%; P = .23). Women were older (median age, 75 vs 72 years for intact; P < .001; 78 vs 73 years for rupture; P < .001) with smaller aortic diameters (57 vs 59 mm for elective; P < .001; 71 vs 79 mm for rupture; P < .001). Arterial injury was more common in women (5.4% vs 2.7%; P = .013) among patients undergoing EVAR for intact aneurysms. Women stayed in the hospital longer (4.3 vs 2.7 days; P = .018) and had lower odds of being discharged home, even after adjusting for age. Among patients undergoing open repair for intact aneurysms, women more frequently experienced leg ischemia/emboli (4% vs 1%; P = .001) and bowel ischemia (5% vs 3%; P = .044). Women had higher 30-day mortality after OAR for intact (4% vs 2%; P = .03) and rupture (48% vs 34%; P = .03) repairs. However, 30-day mortality after EVAR was similar for intact (1% in men vs 1% in women; P = .57) and rupture (29% in men vs 27% in women; P > .99) repairs. Late survival was worse in women than men only for patients undergoing open repair of ruptured aneurysms (hazard ratio, 1.8; 95% confidence interval, 1.0-3.1; P = .04). After controlling for age, type of repair, urgency at presentation (ie, elective/intact vs ruptured), comorbidities, and other relevant risk factors, gender was not predictive of 30-day or 1-year mortality.

Conclusions: Women with AAAs are being treated at older ages and smaller AAA diameters and are undergoing rupture repair at smaller diameters than men. Women are more likely to experience perioperative complications as a result of less favorable vascular anatomy. Age >80 years, comorbidity, presentation, and type of repair are more important predictors of mortality than gender.

FIGURE 1

Gender differences in in-hospital, thirty-day, and one-year mortality following endovascular and open repair of intact and ruptured abdominal aortic aneurysms

FIGURE 2

Survival of patients undergoing open repair of ruptured aneurysms