Abdominal aortic aneurysms

Abstract

Certain biological differences between men and women are relevant to the problem of AAA, and are widely accepted. Women unequivocally have smaller aortas. The size difference correlates with a variety of anthropomorphic measurements, but is most strongly associated with body surface area. In women the compliance of the aorta decreases in linear fashion with age, whereas in men the decrease in compliance is exponential with age. Women appear to be underrepresented in AAA surgical series (typically 18% to 20% of operative cases) compared with autopsy studies (29% to 32%), ultrasound screening studies (19% to 25%), and mortality studies (34% of the 14,982 deaths due to AAA in the US in 1988). Several lines of evidence suggest that women with AAA are less likely than men to be referred for surgery, and that, when referred, they have higher mortality rates. The reasons for these differences are unclear. The very factors that allow increased longevity in women may have an adverse effect on the ability to tolerate a major surgical stress. Wenger et al have suggested that psychosocial and economic factors may affect women's decisions to seek care, or their choice of therapeutic options. Lack of knowledge among practitioners of gender-related aortic size differences and overreliance on simplistic clinical paradigms that dictate operations for 5-cm diameter aneurysms and watchful waiting for 4- to 5-cm AAAs may result in unintended bias in patient selection. It may be that a 5-cm diameter AAA in a woman with a predicted normal aortic size of 1.4 cm represents a more advanced stage of disease than a 5-cm diameter AAA in a man with a normal aortic diameter of 2.5 cm. More precise and detailed algorithms are needed to permit clinicians to tailor decisions to patients' size, sex, and risk factors. Development of such algorithms requires expansion of clinical and epidemiological studies to include enough women to make precise risk estimates.