Sex Differences in Complex Abdominal Aortic Aneurysm: Higher Perioperative Mortality and Morbidity in Female Patients after Endovascular Repair
Livia E.V.M. de Guerre1, Rens R.B. Varkevisser1, Nicholas J. Swerdlow1, Patric Liang1, Chun Li1, Kirsten Dansey1, Joost A. van Herwaarden2, Marc L. Schermerhorn1
1BIDMC, Boston, MA, 2UMCU, Utrecht, Netherlands
Objective: Female sex is associated with worse outcomes following infrarenal abdominal aortic aneurysm (AAA) repair. However, the impact of female sex on complex AAA repair is poorly characterized. More complex anatomy and larger stiffer devices may lead to worse outcomes in female patients undergoing complex AAA repair. Therefore, we compared outcomes between female and male patients following open and endovascular treatment of complex AAA.
Methods: We identified all patients who underwent complex aneurysm repair between 2011 and 2016 in the American College of Surgeons National Surgical Quality Improvement Program Targeted Vascular Module. Complex repairs were defined as those for juxtarenal, pararenal or suprarenal aneurysms. We compared rates of adverse events between females and males, stratified by open and endovascular repair (EVAR). Multivariable logistic regression was used to identify independent associations.
Results: We identified 1477 complex aneurysm repairs, of which 639 were open repairs (29.3% female) and 838 were EVARs (20.2% female). Female patients were older (median age 75 vs. 73 years, P<.001) with smaller aneurysm diameter (median 5.5 vs. 5.7cm, P=.004). Following EVAR, female patients had higher rates of perioperative mortality (5.3% vs. 2.1%, P=.02) and major complications (16% vs. 7%, P<.001). Following open repair, perioperative mortality was not significantly different (7.5% vs. 5.1%, P=.2) and the rate of major complications was similar (27.8% vs. 28.8%, P=.8). Furthermore, even though perioperative mortality was significantly lower after EVAR compared to open repair for male patients (2.1% vs. 5.1%, P=.006), this difference was not significant for women (5.3% vs. 7.5%, P=.4). The perioperative outcomes are shown in Table 1. On multivariable analysis, female sex remained independently associated with higher perioperative mortality (OR 3.1, 95%CI 1.3-7.6, P=.01) and major complications (OR 2.7, 95%CI 1.6-4.5, P<.001) in patients treated
with EVAR, but showed no significant association for mortality (OR .96, 95%CI .44-2.09, P=.9) or major complications after open repair (OR .93, 95%CI .61-1.4, P=.7).
Conclusion: Female sex is associated with higher perioperative mortality and more major complications following complex EVAR, but not following complex open repair. These results should be considered when determining a treatment plan for females with complex AAAs.
| Table 1. Postoperative mortality and complications | ||||||
| Complex Open (n=639) | Complex EVAR (n=838) | |||||
| Male (n=452) | Female (n=187) | P-value | Male (n=669) | Female (n=169) | P-value | |
| Mortality, periop. | 23 (5.1%) | 14 (7.5%) | 0.24 | 14 (2.1%) | 9 (5.3%) | 0.022 |
| Length of stay | 7 (6, 10) | 7 (6, 10) | 0.49 | 2 (1, 3) | 2 (1, 4) | <0.001 |
| ICU length of stay | 3 (1, 5) | 3 (2, 5) | 0.77 | 0 (0, 1) | 0 (0, 1) | 0.34 |
| Operative time | 241.5 (190.5, 313) | 221 (166, 294) | 0.008 | 144 (102, 224) | 162 (106, 251) | 0.025 |
| Any Complication | 143 (31.6%) | 60 (32.1%) | 0.91 | 60 (9.0%) | 31 (18.3%) | <0.001 |
| Major Complication | 130 (28.8%) | 52 (27.8%) | 0.81 | 47 (7.0%) | 27 (16.0%) | <0.001 |
| Minor Complication | 75 (17.0%) | 33 (17.8%) | 0.79 | 32 (4.8%) | 10 (6.1%) | 0.52 |
| Return to the OR | 52 (11.5%) | 24 (12.8%) | 0.64 | 23 (3.4%) | 16 (9.5%) | <0.001 |
| Complications | ||||||
| Respiratory | 75 (16.6%) | 29 (15.5%) | 0.74 | 16 (2.4%) | 5 (3.0%) | 0.67 |
| Cardiac | 31 (6.9%) | 15 (8.0%) | 0.60 | 9 (1.3%) | 3 (1.8%) | 0.67 |
| Renal | 34 (7.5%) | 8 (4.3%) | 0.13 | 8 (1.2%) | 6 (3.6%) | 0.033 |
| Wound | 25 (5.5%) | 9 (4.8%) | 0.71 | 9 (1.3%) | 2 (1.2%) | 0.87 |
| Rupture | 1 (0.2%) | 1 (0.5%) | 0.52 | 1 (0.1%) | 0 (0.0%) | 0.62 |
| Stroke | 1 (0.2%) | 0 (0.0%) | 0.52 | 1 (0.2%) | 4 (2.4%) | <0.001 |
| Ischemic colitis | 23 (5.1%) | 7 (3.7%) | 0.46 | 3 (0.5%) | 4 (2.4%) | 0.014 |
| Lower extremity ischemia | 11 (2.4%) | 5 (2.7%) | 0.86 | 10 (1.5%) | 7 (4.1%) | 0.029 |
| Transfusion | 325 (71.9%) | 136 (72.7%) | 0.83 | 84 (12.6%) | 34 (20.1%) | 0.012 |
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