Self-identified Female Patients Experience Worse Outcomes After Carotid Endarterectomy, Endovascular Abdominal Aortic Aneurysm Repair, And Lower Extremity Amputation: Gender Disparities In Vascular Surgery
Brian M. Leoce, BS1, Syed F. Haider, MD1, Kasey Leigh Wood, BS2, Mario M. Matabele, BS2, Frank T. Padberg, MD1, Joe T. Huang, MD1, Michael A. Curi, MD1, Aziz M. Merchant, MD1, Saqib Zia, MD1.
1Rutgers New Jersey Medical School, Newark, NJ, USA, 2University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Introduction Carotid endarterectomy (CEA), endovascular abdominal aortic aneurysm repair (EVAR), and below knee amputation (BKA) are frequently performed procedures in vascular surgery. Controlling for a naturally occurring higher prevalence of vascular disease in the biological male population, this study seeks to determine if gender disparities exist in the outcomes of these commonly performed procedures. Methods The American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database was queried from 2012-19, and all cases of CEA, EVAR, and BKA were identified. Preoperative, operative, and postoperative variables were recorded. Propensity score matching algorithms were conducted to evaluate the independent association of gender. Severe postoperative complications include sepsis, myocardial infarction, deep surgical site infection, pulmonary embolism, renal failure, stroke, and death. Minor postoperative complications include urinary tract infection, superficial surgical site infection, and pneumonia. Significance was achieved at p ≤0.05. Results Database query isolated a total of 100,191 procedures (79,729, 6,588, and 13,874 cases of CEA, EVAR, and BKA respectively), yielding a combined total of 62,830 self-identified male and 37,361 self-identified female patients. After propensity score matching, CEA, EVAR, and BKA cohorts contained 14,094, 4,136, and 13,068 patients respectively. Analysis of these matched groups indicated that female patients had a statistically significant decreased risk of death in the CEA cohort (p = 0.007), an increased risk of any, severe, or minor postoperative complications (p <0.001, p <0.001, p = 0.001) and reoperation or readmission (p<0.001, p=0.001) in the EVAR cohort, and increased risk of any, severe, or minor postoperative complications (p <0.001, p <0.001, p = 0.004) as well as increased risk of readmission or death (p = 0.001, p = 0.036) in the BKA cohort when compared to their male counterparts. There were no significant associations between any of the pre-operative variables within the propensity score matched groups. Conclusions There appears to be a significant gender disparity in the outcomes of all studied procedures. This warrants further investigation, specifically into why female vascular patients, despite having an overall lower prevalence of vascular disease compared to male vascular patients, face worse outcomes postoperatively. Table 1. Association between female gender and incidence of postoperative complications via analysis of propensity score matched groups. 
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