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Iliac Artery Exposure Independently Predicts Mortality in Female Patients Undergoing Thoracic Endovascular Aortic Aneurysm Repair (TEVAR): An Analysis of the ACS-NSQIP Database
George J. Arnaoutakis, MD, James H. Black, III, MD, Eric B. Schneider, PhD, Ying W. Lum, MD, Mahmoud B. Malas, MD, Bruce A. Perler, MD, MBA, Julie A. Freischlag, MD, Christopher J. Abularrage, MD.
The Johns Hopkins Hospital, Baltimore, MD, USA.
OBJECTIVES:
Previous studies have shown that female gender is associated with increased morbidity and mortality following endovascular abdominal aortic aneurysm repair. The goal of this study was to assess the effect of gender on the 30-day outcomes of thoracic endovascular aortic aneurysm repair (TEVAR) using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database.
METHODS:
This was a review of the 2005-2010 ACS-NSQIP database to identify all patients who underwent TEVAR for nonruptured thoracic aortic aneurysm. Procedure and diagnosis codes were used to capture the study population. Patients were stratified according to gender, and baseline, operative, and outcomes data were compared in bivariate fashion. 30-day mortality was the primary outcome measure, and a multivariable logistic regression model was used to identify independent associations.
RESULTS:
649 patients underwent TEVAR during the study period, with 279 (43%) women and 370 (57%) male. Baseline demographics according to gender were similar, however women were less likely to drink alcohol (1 vs. 5%; p=.001) and less likely to have a history of cardiac surgery (14 vs. 27%; p<.001). More women required iliac artery exposure (18 vs. 7%; p=<.001). Operative times (173.6±6.3 vs. 159.8±5.2 min; p=.03), transfusion rates (30 vs. 17%, p=.001), and hospital length of stay (7.7±0.5 vs. 7.6±0.5 days; p=.009) were increased in women compared to men. Overall postoperative complications were similar between the two groups, but unadjusted mortality was significantly greater in women (6 vs.3%; p=.03). On multivariable analysis, female gender was no longer a significant predictor of mortality (OR 2.30; 95% CI [0.99-5.34]; p=.053). Independent predictors of 30-day mortality included increasing age (OR 1.05, 95% CI [1.01-1.09]; p=.02), emergency procedure (OR 3.76; 95% CI [1.79-7.87]; p<.001), and iliac artery exposure (OR 4.42; 95% CI [2.07-9.44]; p<.001).
CONCLUSIONS:
30-day mortality is increased in women compared to men. This seems to be explained by an increased need for iliac artery exposure which results in increased operative times, transfusion rates, and thirty-day mortality following TEVAR for unruptured thoracic aortic aneurysms. These findings represent a strong need for decreased device delivery size and improvements in endovascular technology.
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