Female Sex is a Marker for Higher Morbidity and Mortality after Elective Endovascular Aortic Aneurysm Repair: A National Surgical Quality Improvement Program Analysis

Abstract

The adverse gender disparities for women after open abdominal aortic aneurysm (AAA) repair have been well documented. The purpose of this study is to review whether these disparities extend to elective endovascular aneurysm repair (EVAR). Nonruptured, elective AAA was identified from the American College of Surgeons' National Quality Improvement Program (NSQIP) Targeted Participant Use File for EVAR from 2012 to 2017. The primary outcome was mortality. Secondary outcomes included lower extremity ischemia requiring intervention (LEIRI) and prolonged operative time (>120min). Multivariable logistic regression models were used to assess the risk of mortality, LEIRI, and prolonged operative time among women compared with men. There were 14,019 EVAR procedures captured. A total of 3,367 were included for analysis after limiting to nonruptured, elective cases for diagnosis of AAA with a Current Procedural Terminology procedure code for EVAR. Of those, 2,764 (82.1%) were performed in men and 603 (17.9%) in women. Female patients were older (median [interquartile range (IQR)] 77years [70-82] versus 74years [68-80], P<0.001), more likely to smoke (35.5% versus 29.6%, P=0.005), and less likely to have diabetes (12.4% versus 17.8%, P=0.001). Women had slightly smaller AAA size (median [IQR] 5.4cm [5.0-5.9] versus 5.5cm [5.1-6.0], P<0.001) and were more likely to have prior abdominal operations (35.3% versus 23.1%, P<0.001). The operative time was longer among women (median 114min. [85-150] versus 105min. [82-140], P<0.001). Postoperatively, mortality was higher in female patients (1.8% versus 0.9%, P=0.036), LEIRI occurred in higher proportion among female patients (2.7% versus 1.2%, P=0.009), and their hospital stay was also longer (median 2days [1-3] versus 1day [1-2] days, P<0.001). On multivariable logistic regression analysis, hematocrit level <30 vol% versus ≥30 vol% (odds ratio (OR) 5.5, 95% confidence interval (CI) 2.1-14.5, P<0.001) was associated with increased mortality. Although not statistically significant, there was also evidence that the odds of mortality were also greater among women (OR 2.0, 95% CI 0.98-4.2, P=0.06). LEIRI was more likely among women (OR 2.1, 95% CI 1.2-3.9, P=0.015) and patients with a smoking history (OR 1.8, 95% CI 1.0-3.2, P=0.044). Finally, odds of prolonged operative time were higher among women (OR 1.4, 95% CI 1.2-1.7, P<0.001) and patients with chronic obstructive pulmonary disease (OR 1.2, 95% CI 1.0-1.5, P=0.033) or partial/total dependent functional status (OR 2.2, 95% CI 1.3-3.7, P=0.003). Although EVAR has improved overall surgical AAA outcomes, the NSQIP data in elective EVAR demonstrate continued sex disparities in morbidity and mortality after AAA surgical repair to the detriment of female patients.