Sex Differences in Perioperative Outcomes After Complex Abdominal Aneurysms Repair

Abstract

Introduction: Female sex is associated with worse outcomes following infrarenal abdominal aortic aneurysm (AAA) repair. However, the impact of female sex on complex AAA repair is poorly characterized. Therefore, we compared outcomes between female and male patients following open and endovascular treatment of complex AAA. Methods: We identified all patients who underwent complex aneurysm repair between 2011 and 2017 in a national quality improvement database. Complex repairs were defined as those for juxtarenal, pararenal or suprarenal aneurysms. We compared rates of perioperative adverse events between females and males, stratified by open and endovascular repair (EVAR). We calculated propensity scores and used inverse probability weighted logistic regression to identify independent associations between female sex and our outcomes. Results: We identified 2,270 complex aneurysm repairs, of which 1,260 were EVARs (21.4%% female) and 1,010 were open repairs (30.7% female). Following EVAR, female patients had higher rates of perioperative mortality (6.3% vs 2.4%; P=.001) and major complications (15.9% vs. 7.6%, P< .001) compared to males. In contrast, following open repair, perioperative mortality was not significantly different (7.4% vs. 5.6%, P=.3) and the rate of major complications was similar (29.4% vs. 27.4%, P=.53) between females and males. Furthermore, even though perioperative mortality was significantly lower after EVAR compared to open repair for male patients (2.4% vs. 5.6%, P=.001), this difference was not significant for women (6.3% vs. 7.4%, P=.60). On multivariable analysis, female sex remained independently associated with higher perioperative mortality (OR, 2.5; 95% CI, 1.3-4.9; P=.007) and major complications (OR, 2.0; 95% CI, 1.3-3.2; P=.002) in patients treated with EVAR, but showed no significant association with mortality (OR, 0.89; 95% CI, 0.5-1.6; P=.69) or major complications (OR, 1.1; 95% CI, 0.8-1.5; P=.74) after open repair. However, the association of female sex with higher perioperative mortality in patients undergoing complex EVAR was attenuated when diameter was replaced with Aortic Size Index in the multivariable analysis (OR, 1.9; 95% CI, .91-3.9; P= .091). Conclusion: Female sex is associated with higher perioperative mortality and more major complications than male patients following complex EVAR, but not following complex open repair. Continuous efforts are warranted to improve the sex discrepancies in patients undergoing endovascular repair of complex AAA. Disclosure: JH is a consultant for Medtronic and Bolton Medical MS is a consultant for Abbott Vascular, Cook Medical, Endologix, Medtronic, and Silk Road. * This study has been presented at the SCVS 2019 karmody competition * This study has been submitted and is under revision at the journal of vascular surgery