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COMPARATIVE STUDY
JOURNAL ARTICLE

Women derive less benefit from elective endovascular aneurysm repair than men

Manish Mehta, W John Byrne, Handel Robinson, Sean P Roddy, Philip S K Paty, Paul B Kreienberg, Paul Feustel, R Clement Darling
Journal of Vascular Surgery 2012, 55 (4): 906-13
22322123

BACKGROUND: Women have a lower chance of surviving elective open abdominal aortic repair. The reasons for this are not clear. Endovascular repair has clearly reduced early and midterm morbidity and mortality for patients with large abdominal aortic aneurysms (AAAs). However, most patients are male. It is unclear whether there has been any reduction in elective morbidity for females or what the extent of that reduction has been. We prospectively analyzed outcomes for elective endovascular aneurysm repair (EVAR) in women at our center and compared results with those for elective open surgery and emergent open and endovascular repair.

METHODS: All patients undergoing elective and emergency AAA from 2002 to 2009 were prospectively entered into a database. Demographic details, including gender, were tabulated. Outcome measures were operative blood loss, incidence of type 1 endoleaks, length of in-hospital stay, postoperative complications, 30-day all-cause mortality, and secondary interventions during the follow-up period. Statistical analysis was performed using Fischer exact test and Student t test. A multivariate analysis was also performed.

RESULTS: From 2002 to 2009, there were 2631 abdominal aortic aneurysms (AAA) open and endovascular repairs performed in our center (1698 endovascular aneurysm repairs [EVARs], 933 "open"). Males comprised 1995 (76%) of patients; females 636 (24%). There were 1592 elective EVARs (1248 male, 344 female) and 106 emergency EVARs (73 male, 33 female). Elective open repair was performed in 788 patients (579 male, 209 female) and emergency open repair in 149 (73 male, 76 female). For women, elective EVAR resulted in significantly greater mortality rates than men (3.2% vs 0.96%, P < .005). There was a greater incidence of intraoperative aortic neck or iliac artery rupture (4.1% vs 1.2% P = .002) and use of Palmaz stents for type 1 endoleaks (16.1% vs 8%, P = .0009). Mean blood loss was greater in females (327 mL vs 275 mL, P = .038). Perioperative complications were also more frequent in women: leg ischemia (3.5% vs 0.6%, P = .003) and colon ischemia requiring colectomy (0.9% vs 0.2%, P = .009). Mean hospital stay was also longer (3.7 days vs 2.2 days, P = .0001). In contrast, there were no gender differences for any of these outcome measures for elective open repair or emergency open surgery or EVAR. There was no significant difference in death rates between EVAR and open repair in women (3.2% vs 5.7%). In males, the 30-day mortality was 0.96% for elective EVAR and 4.7% for elective open surgery. Following logistic regression, female gender remains a significant risk even when the effects of aneurysm size and age are considered (odds ratio 3.4, P < .01).

CONCLUSIONS: Mortality for females undergoing elective EVAR is significantly greater than for males. It is also more hazardous. Colon ischemia, native arterial rupture, and type 1 endoleaks are more frequent. Elective endovascular aneurysm repair benefits men more than women.

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