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Impact of Gender on Outcomes following Abdominal Aortic Aneurysm Repair.
Satinderjit Locham, MD1, Abdelrahman Sherif Saeed Shaaban2, Hanaa Dakour-Aridi, MD1, Linda J. Wang, MD, MBA3, Marc Schermerhorn, MD4, Mahmoud Malas, MD, MHS, FACS1.
1University of California San Diego, La Jolla, CA, USA, 2Johns Hopkins University School of Medicine, baltimore, MD, USA, 3Massachusetts General Hospital, Boston, MA, USA, 4Beth Israel Deaconess Medical Center, Boston, MA, USA.

OBJECTIVES: The majority of studies on aortic neck anatomy and gender are limited to single center institutions. The purpose of this study is to use a large nationally representative vascular database and assess the differences in patient’s characteristics, aortic neck anatomy, and outcomes between females versus males following open (OAR) and endovascular (EVAR) repair.
METHODS: Patients undergoing AAA repair from 2003-2017 in VQI were stratified by procedure (EVAR vs OAR). An EVAR subset analysis was performed to assess differences in aortic neck anatomy; hostile neck (HN) anatomy was defined as: length<15mm (L<15), angle>60 (A>60), and/or diameter>28mm (D>28). Standard univariate and multivariable analysis were performed.
RESULTS: 37,053 patients were identified: 7,458 (20%) OAR and 29,595 (80%) EVAR. In both cohorts, majority of patients were males (OAR 74%, EVAR 81%). On EVAR subset analysis, females were more likely to have a HN (32.0% vs. 24.8%), L<15 (19.8% vs. 12.6%), and A>60 (11.0% vs. 5.4%)(All p<.001). Men had larger maximum aneurysm diameter (mean in millimeters±S.D.: 57±16 vs. 55±11) and were more likely to have D>28 (14.0% vs. 11.5%)(both p<.001). In regards to the operative characteristics, females undergoing EVAR were more likely to have multiple aortic extensions (23.3% vs. 17.8%), thrombo/embolectomy (1.4% vs. 0.8%), and receive higher contrast volume. In univariate analysis, females undergoing OAR had higher 30-day mortality, transfusion, lower extremity ischemia and pulmonary complications. While all adverse events were higher among females versus males following EVAR. After adjusting for potential confounders, female gender was associated with 70% and 64% increase risk of 30-day mortality in OAR and EVAR, respectively (table). Renal, cardiac and pulmonary complications were significantly higher in females versus males undergoing EVAR. Additionally, females were also at an increase odds of developing type-1 endoleak at completion.
CONCLUSIONS: Our study demonstrates unfavorable neck anatomy occurs more frequently in females compared to males. This resulted in increased risk of developing type I endoleak intraoperatively and increases in the number of proximal endograft extensions. 30-day mortality was significantly higher in females undergoing AAA repair. Careful patients’ selection is indicated in all patients to reduce complications, with special attention in females with hostile neck.

Logistic regression analysis of major adverse events between females versus males.
Open Repair 1Endovascular Repair 2
OR (95% CI)P-ValueOR (95% CI)P-Value
30-day Mortality1.70(1.24-2.35)0.0011.64(1.23-2.20)0.001
In-Hospital complications
Acute Renal Failure0.85(0.70-1.03)0.091.39(1.18-1.64)<0.001
Cardiac0.87(0.74-1.04)0.131.39(1.17-1.66)<0.001
Pulmonary0.92(0.75-1.12)0.411.59(1.28-2.00)<0.001
Type 1 Endoleak at completion *--3.54(1.56-8.09)<0.001
1 Adjusted for gender, age, race, urgency, obesity, smoker, diabetes, hypertension, coronary artery disease, COPD, preoperative creatinine, severity of anemia, history of aortic surgery, aspirin, statin, maximum AAA diameter, iliac aneurysms, blood loss, exposure, distal anastomosis, proximal clamp location, hypogastric occlusion, concomitant renal bypass, and hospital volume.
2 Adjusted for gender, age, race, urgency, obesity, smoker, diabetes, hypertension, coronary artery disease, Congestive heart failure, COPD, preoperative creatinine, severity of anemia, Family history of AAA, aspirin, statin, maximum AAA diameter, iliac aneurysms, blood loss, and hospital volume.
* Only included patients who underwent endovascular repair from 2015 to 2017 and adjusted for additional endovascular specific variables (hostile anatomy, supraneck angle, proximal neck angle, neck length, neck diameter, iliac diameter, incision, distal extent of aneurysm, contrast, and proximal aortic extensions).


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