Objective Medicare studies have shown increased perioperative mortality in women compared to men following endovascular and open AAA repair. However, a recent regional study of high-volume centers, adjusting for anatomy but limited in sample size, did not show sex to be predictive of worse outcomes. This study aims to evaluate sex differences after intact AAA repair in a national clinical registry. Methods The Targeted Vascular module of NSQIP was queried to identify patients undergoing EVAR or open repair for intact, infrarenal AAA from 2011–2014. Univariate analysis was performed using the Fisher Exact test and Mann-Whitney test. Multivariable logistic regression was utilized to account for differences in comorbidities, aneurysm details, and operative characteristics. Results We identified 6,661 patients (19% women) who underwent intact AAA repair (87% EVAR; women 83% vs. men 88%, P < .001). Women were older (median age 76 vs. 73, P < .001), had smaller aneurysms (median 5.4 cm vs. 5.5 cm, P < .001), and more COPD (22% vs. 17%, P < .001). Amongst patients undergoing EVAR, women had longer operative times (median 138 [IQR 103–170] vs. 131 [106–181] minutes, P < .01) and more often underwent renal (6.3% vs. 4.1%, P < .01) and lower extremity revascularization (6.6% vs. 3.8%, P < .01). After open repair, women had shorter operative time (215 [177–304] vs. 226 [165–264] minutes, P = .02), but women less frequently underwent lower extremity revascularization (3.1% vs. 8.2%, P = .03). Thirty-day mortality was higher in women after EVAR (3.2% vs. 1.2%, P < .001) and open repair (8.0% vs. 4.0%, P = .04). After adjusting for repair type, age, aneurysm diameter, and comorbidities, female sex was independently associated with mortality (odds ratio [OR] 1.7, 95% confidence interval [CI]: 1.1 – 2.6; P = .02) and major complications (OR 1.4, CI: 1.1 – 1.7; P < .01) after intact AAA repair. However, after adjusting for aortic size index rather than aortic diameter, the association between female sex and mortality (OR 1.5, CI: 0.98 – 2.4; P = .06) and major complications (OR 1.1, CI: 0.9 – 1.4; P = .24) was reduced. Conclusions Women were at higher risk for 30-day death and major complications after intact AAA repair. Some of this disparity may be explained by differences in aortic size index, which should be further evaluated to determine the ideal threshold for repair.

Background Higher hospital and surgeon volumes are independently associated with improved mortality following open repair of abdominal aortic aneurysms (AAA) in the era prior to endovascular repair (EVAR). The effects of both surgeon and hospital volume on mortality following EVAR and open repair in the current era are less well defined. Methods We studied Medicare beneficiaries who underwent elective AAA repair from 2001–2008. Volume was measured by procedure type over the one-year period preceding each procedure and was further categorized into quintiles (Q) of volume for both surgeon and hospital. Multilevel logistic regression models were used to evaluate the effect of surgeon volume, accounting for hospital volume, on mortality, adjusting for patient demographic and comorbid conditions as well as the analogous effect of hospital volume adjusting for surgeon volume. The multilevel models included random effects for surgeon and hospital to account for the clustering of multiple patients within the same surgeon and within the same hospital. Results We studied 122,495 patients who underwent AAA repair (Open: 45,451, EVAR: 77,044). Following EVAR, perioperative mortality did not differ by surgeon volume (Q1 (0–6 EVARs): 1.8%, Q5 (28–151 EVARs): 1.6%, P = 0.29), but decreased with greater hospital volume (Q1 (0–9 EVARs): 1.9%, Q5 (49–198 EVARs): 1.4%, P < .01). Following open repair, perioperative mortality decreased with both higher surgeon volume (Q1 (0–3 open repairs): 6.4%, Q5 (14–62 open repairs): 3.8%, P < .01) and hospital volume (Q1 (0–5 open repairs): 6.3%, Q5 (14–62 open repairs): 3.8%, P < .01). After adjustment for other predictors, surgeon volume was not associated with perioperative mortality after EVAR (OR:0.9, 95% CI:0.7–1.1); however, there was an association between hospital volume and higher perioperative mortality (Q1(OR: 1.5, 95% CI:1.2–1.9), Q2 (OR:1.3, 95% CI:1.02–1.6), and Q3 (OR:1.2, 95% CI:1.01–1.5) as compared to Q5). Following open repair, higher surgeon volume was also associated with lower mortality (Q1 (OR:1.5, 95% CI:1.3–1.8), Q2 (OR:1.3 95% CI:1.1–1.6), and Q3 (OR:1.2, 95% CI:1.1–1.4) compared with Q5). Risk of mortality also was higher for patients treated at lower volume hospitals (Q1 (OR:1.3, 95% CI:1.1–1.5), Q2 (OR:1.3, 95% CI:1.1–1.5), and Q3 (OR:1.2, 95% CI:1.1–1.4) versus Q5). Conclusion Following EVAR, hospital volume is minimally associated with perioperative mortality with no such association for surgeon volume. Following open AAA repair, both surgeon and hospital volume are strongly associated with mortality. These findings suggest that open surgery should be concentrated in hospitals and surgeons with high volume.

Objective While sex differences in the pathogenesis, presentation, and outcomes of repair for abdominal aortic aneurysms are well studied, less is known about sex differences following thoracic endovascular aneurysm repair (TEVAR). The goal of this study was to evaluate the association between sex and morbidity and mortality following TEVAR. Methods A retrospective review of all TEVAR in the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) registry from 2011–2015 was conducted, excluding those with dissection, trauma, and rupture. Statistical analysis was performed using the Fisher’s exact test and the Mann-Whitney U test for categorical and continuous variables. Multivariable logistic regression and Cox hazards modeling were used to account for differences in demographics, comorbidities, and aneurysm characteristics in 30-day mortality and long-term survival. Results We identified 2,574 patients (40% women) who underwent TEVAR. Women were older, less likely white, and had smaller aortic diameters but larger aortic size indices (aortic diameter/body surface area). Women also had more chronic obstructive pulmonary disease, but less coronary artery disease and fewer coronary interventions. Women were more likely to be symptomatic at presentation and subsequently have a non-elective procedure. Women had higher estimated blood loss (EBL > 500cc: 20% vs. 17%, P = .04), were more likely to be transfused (29% vs. 21%, P < .001), and more frequently underwent iliac access procedures (4.3% vs. 2.1%, P < .01). Operative time and left subclavian intervention were similar. Postoperatively, women had increased median hospital (5 vs. 4 days, P < .001) and intensive care unit lengths of stay (2.5 vs. 2, P < .001) and were less likely discharged home (75% vs. 86%, P < .001). Mortality was higher for women at 30 days (5.4% vs. 3.3%, P < .01) and one year (9.8% vs. 6.3%, P < .01). After adjusting for age, aortic size index, symptoms, and comorbidities, female sex remained independently predictive of 30-day (OR 1.5, 95% CI: 1.1–2.1, P < .01) and long-term mortality (HR 1.3, 95% CI: 1.03–1.6, P = .02). Conclusions Even after adjusting for differences in age and comorbidities, female patients have higher perioperative mortality and lower long-term survival following TEVAR. These findings, along with the rupture risk by sex, should be considered by clinicians when determining the timing of intervention.

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Objective Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment. Methods Patients undergoing non-emergent infrainguinal bypass between 2011 and 2014 were identified in the NSQIP-Targeted Vascular module. After stratification by symptom status (chronic limb-threatening ischemia [CLTI] and claudication), patients undergoing primary bypass were compared to those undergoing secondary bypass. Within the secondary bypass group, further analysis compared prior bypass to prior endovascular intervention. Multivariable logistic regression analysis was used to establish the independent association between prior ipsilateral procedure and perioperative outcomes. Results A total of 7302 patients were identified, of which 4540 (62%) underwent primary bypass (68% for CLTI), 1536 (21%) underwent secondary bypass after a previous bypass (75% for CLTI), and 1226 (17%) underwent secondary bypass after a previous endovascular intervention (72% for CLTI). Prior revascularization on the same ipsilateral arteries was associated with increased 30-day major adverse limb event in patients with CLTI (9.8% vs. 7.4%; OR: 1.4, 95% CI: 1.1–1.7) and claudication (5.2% vs. 2.5%; 2.1, 1.3–3.5). Similarly, secondary bypass was an independent risk factor for 30-day major reintervention (CLTI: 1.4, 1.1–1.8; claudication: 2.1, 1.3–3.5), bleeding (CLTI: 1.4, 1.2–1.6; claudication: 1.7, 1.3–2.4), and unplanned reoperation (CLTI: 1.2, 1.0–1.4; claudication: 1.6, 1.1–2.1), whereas major amputation was increased in CLTI patients only (1.3, 1.0–1.8). Perioperative mortality was not significantly different in patients undergoing secondary compared to primary bypass (CLTI: 1.7% vs. 2.2%, P = .22; claudication: 0.4% vs. 0.6%, P = .76). Among secondary bypass patients with CLTI, those with prior bypass had higher 30-day reintervention rates (7.8% vs. 4.9%; OR: 1.5, 95% CI: 1.0–2.2), but fewer wound infections (7.3% vs. 12%; 0.6, 0.4–0.8) compared to patients with prior endovascular intervention. Conclusions Prior revascularization, in both patients with CLTI and claudication, is associated with worse perioperative outcomes compared to primary bypass. Furthermore, prior endovascular intervention is associated with increased wound infections, whereas those with prior bypass had higher reintervention rates. The increasing prevalence of patients undergoing multiple interventions stresses the importance of patient selection for initial treatment and should be factored into subsequent revascularization options in an effort to decrease adverse events.