Commentary on ‘Gender related Outcome Inequalities in Endovascular Aneurysm Repair’. Please still take good care of the ladies

Abstract

In a well conducted English nationwide population based historical cohort study by Lowry et al.,1Lowry D. Singh J. Mytton J. Tiwari A. Gender related outcome inequalities in endovascular aneurysm repair.Eur J Vasc Endovasc Surg. 2016; 52: 526Abstract Full Text Full Text PDF Scopus (27) Google Scholar female gender was associated with poorer outcome after EVAR after adjustment for age, deprivation, co-morbidities, and trust volume. They concluded that being female was associated with an increased independent risk for a length of stay of more than 3 days, re-admission within 30 days, re-admission within 1 year, 30 day mortality, and 1 year mortality following EVAR, but the clinical impact of their observations seems sparsely addressed. The Charlson Index was used to adjust for comorbidities, but it was developed for long-term survival studies, and not short-term studies on post-operative outcomes. It includes irrelevant comorbidities and excludes relevant comorbidities regarding operative risks.2Charlson M.E. Pompei P. Ales K.L. MacKenzie C.R. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373-383Abstract Full Text PDF PubMed Scopus (34492) Google Scholar Consequently, serious risks of residual confounding are present. To minimise residual confounding, adjustment ought to have included robust independent risk factors concerning comorbidity, smoking, BMI, and aneurysm morphology, as well as diagnosis by population based screening, as that is associated with a one third risk compared with incidentally detected cases and only offered to men in England.3Lindholt J.S. Norman P.E. Meta-analysis of post-operative mortality after elective repair of abdominal aortic aneurysms detected by screening.Br J Surg. 2011; 98: 619-622Crossref PubMed Scopus (40) Google Scholar However, this was probably not possible because of the nature of the study. Female gender seems to be a marker of a potentially higher risk profile for treatment. Here the catch up concerning overall mortality is noticeable, as there is no gender difference after 5 years. It could be interpreted that the poorer short-term outcomes are mainly the result of technical reasons. Short-term post-operative outcome parameters are excellent for quality assurance of treatments; However, the most efficient and fastest way to improve a bad record by only “picking the winners.” One could fear women would lose such selection because of reports like the current one. From the society's and the patient's points of view, this would be a mistake as quality assessment parameters do not say much about the benefit and cost-effectiveness of the treatment, but only about the potential harm. The benefit and cost-effectiveness of preventive AAA repair lies in the societal costs and gained quality adjusted living years; included in evaluation of the overall benefits and costs. The numbers needed to treat to prevent one rupture must be considerably lower in women than men, as the rupture risk in each AAA size grouping is three or four times increased in women.4Sweeting M.J. Thompson S.G. Brown L.C. Powell J.T. RESCAN collaboratorsMeta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms.Br J Surg. 2012; 99: 655-665Crossref PubMed Scopus (353) Google Scholar This difference could easily justify the 1.25 times increased risk when repairing women. Recently, a unique and modern AAA survival model in health technology assessment identified age, female sex, IHD, abnormal ECG, anaemia, abnormal serum sodium, and creatinine > 120 μmol/L as predictors of poorer long-term survival following AAA repair, with statin and antiplatelet therapy associated with improved survival.5Grant S.W. Sperrin M. Carlson E. Chinai N. Ntais D. Hamilton M. et al.Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation.Health Technol Assess. 2015; 19: 1-154Crossref Scopus (17) Google Scholar They recommended these factors should be considered when making clinical decisions but concluded overall that the indication for elective AAA repair at 5.0 cm in women is applicable to most female patients; their developed model can assist surgeons and their patients to make a more individualised and informed decision but needs to be evaluated first. So until then: please still take good care of the ladies. Sex-related Outcome Inequalities in Endovascular Aneurysm RepairEuropean Journal of Vascular and Endovascular SurgeryVol. 52Issue 4PreviewWomen are known to have a higher rate of postoperative complications and mortality following open abdominal aortic aneurysm (AAA) repair. It is less clear whether this remains true of endovascular aneurysm repair (EVAR). This study examines the association between sex and hospital length of stay (LoS), readmission rates, and mortality following elective EVAR in the population of England between April 2006 and March 2015. Full-Text PDF Open Archive