The gender initiative continues with editorials addressing noncardiac vascular surgery: (1) Experts discuss sex-based differences in the prevalence of vascular disease; (2) the pathophysiology, risks, and benefits of surgical treatment of carotid disease in women; (3) the need for clarifying optimal timing for surgical repair of abdominal aortic aneurysms in women and for refining endovascular repair technology for small patients; and (4) current outcomes (limb salvage, graft patency, and mortality) and future research in women with peripheral arterial occlusive disease. The series continues next month with editorials on end-stage heart failure.

We describe a case of severe coagulopathy after mesenteric revascularization. Laboratory investigation results revealed the presence of plasma inhibitors of factor V believed to result from exposure to bovine thrombin used for intraoperative hemostasis. Vascular and cardiothoracic surgeons commonly use topical thrombin for surgical hemostasis, and many patients undergo multiple exposure. More patients likely have factor V inhibitors develop than has previously been realized, and this may account for some otherwise unexplained postoperative coagulation disorders. This report may alert surgeons to coagulation disturbances that can result from exposure to bovine thrombin and provide guidelines for diagnosis and management.

See related editorials on pages 314, 318, and 322.T he prevalence of abdominal aortic aneurysms (AAAs) has been reported to be higher in men than in women. Most prevalence studies (AAA diagnosed by means of autopsy, ultrasound screening, and hospital discharge data) demonstrated the percentage of AAAs diagnosed in women to be 19% to 34% and the percentage diagnosed in men to be 66% to 81%. [1][2][3][4][5] This rate appears to be reliably constant in many Western nations. No cause or causes for the dramatic difference in the prevalence of AAAs between the sexes has been identified.Risk-factor profiles appear to be similar for both sexes. Age, cigarette smoking, and family history are all reported to have high association with AAA formation. 5,6 Women are usually older than their male counterparts when they undergo AAA repair (Tables 1 and 2). 1,[6][7][8][9][10][11][12] Men have a higher association of ischemic coronary artery disease and peripheral aneurysms (usually femoral or popliteal in location), and women have a higher incidence of concomitant aortoiliac occlusive disease. 6 The decision of when to recommend repair of an AAA for women is debatable. The general consensus is that the rupture rate increases with increasing aortic diameter. The rupture rate increases dramatically as the aneurysm diameter approaches 5 cm. Generally, when the aneurysm attains this size, treatment is recommended for low-risk patients in the United States. Similarly, a 5.5-cm aneurysm diameter is used for this standard in the United Kingdom. Data concerning the optimal timing of repair have been generated primarily in men. Measurement of AAA diameter, combined with close analysis of the individual patient's surgical risk, has been used historically to make operative recommendations. The optimal timing of repair on the basis of aortic diameters for women has not been clearly defined. The risk-benefit analysis might be different for women. The UK Small Aneurysm Trial demonstrated a 3-fold increase in the incidence of rupture of an AAA when controlling for aneurysm size in women compared with men. 4 Therefore do normal aortas differ in size between men and women? A study designed to screen the size of abdominal aortas by using ultrasonography reported significant differences in normal aortic diameter between the sexes, as well as based on body mass indices and body surface area. 13 In this study a total of 122,272 men and 3450 women were screened. Normal aortic diameter differed between men and women by 0.14 cm (women having the smaller aortic diameter). 13 This finding is statistically significant, but the absolute size difference between men and women is small.Several studies that examined hospital data (prevalence of AAAs and subsequent surgical treatment) suggested that women are offered surgical repair of AAAs at an alarmingly lower rate than their male counterparts. 7,10,11 Unfortunately, these studies could not provide further data regarding the decision not to repair the AAA. Perhaps the women decided to forego therapy. Also po...

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See related editorials on pages 314, 322 and 325.