Female Sex Portends Worse Long-term Survival After Open Type I-III Thoracoabdominal Aneurysm Repair
CHRISTOPHER A. LATZ, M.D., M.P.H., Laura Boitano, M.D., M.P.H., Linda J. Wang, M.D., M.B.A, Elizabeth Chou, M.D., Charles DeCarlo, M.D., Anna A. Pendleton, M.D., Jahan Mohebali, M.D., M.P.H., Mark Conrad, M.D., MMSc..
MASSACHUSETTS GENERAL HOSPITAL, BOSTON, MA, USA.
OBJECTIVES: Although outcomes following infrarenal abdominal aortic aneurysm surgery are worse in females, sex-specific differences in outcomes following open thoracoabdominal aortic aneurysm (TAAA) surgery are less clear. The goal of this study was to identify sex-based disparities in short and long-term outcomes after open type I-III TAAA surgery.
METHODS: All open type I-III TAAA repairs performed from1987-2015 were evaluated using an institutional database. Charts were retrospectively evaluated for peri-operative outcomes: major adverse event (MAE), in-hospital death, and long-term survival. Univariate analysis was performed using the Fisher’s exact test for categorical variables and the Wilcoxon rank-rum test for continuous variables. Logistic regression was used for in-hospital endpoints; survival analyses were performed with Cox proportional hazards modelling and Kaplan-Meier techniques. Sensitivity analyses were performed for relevant multivariable models, one with ruptures removed and another evaluating only repairs performed before 2006 to account for any selection bias due to wider use of complex endovascular technology.
RESULTS: Five hundred sixteen patients had an open type I-III TAAA repair during the study period. 280 (54.3%) were female. Females were older, less likely to have a chronic dissection etiology, were more likely to present with a symptomatic/ruptured lesion and had a lower admission creatinine. 23 (9.8%) males and 19(6.8%) females died perioperatively (p=0.26); 133 females (47.3%) and 116 males (49.2%) suffered a MAE (p=0.72). Multivariable analyses revealed no sex-based difference in peri-operative death (Female sex AOR:0.72, 95% CI:0.4-1.4, p=0.34) or MAE (AOR:1.0 CI:0.7-1.5, p=0.82). Unadjusted survival at five-years was 50% for females and 67% for males (log-rank p<0.001). Female sex was an independent predictor of decreased survival (HR:1.5 95% CI:1.2-1.9, p=0.001), when adjusted for age, extent, creatinine, diameter and symptomatic presentation. After removing all ruptures, female sex remained non-predictive of peri-operative death (AOR:1.1, 95% CI 0.5-2.5, p=0.75) or MAE (AOR:1.2, CI:0.8-1.9, p=0.31), and predictive of decreased survival (HR:1.6, 95% CI:1.2-2.0, p=0.001). Female sex remained predictive of decreased survival when only repairs prior to 2006 were considered.
CONCLUSIONS: Despite similar perioperative outcomes, women suffer from decreased long-term survival after open type I-III TAAA surgery.
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