Editor's Choice – Systematic Review and Meta-Analysis of Sex Specific Differences in Adverse Events After Open and Endovascular Intact Abdominal Aortic Aneurysm Repair: Consistently Worse Outcomes for Women

Abstract

This study demonstrates that the risk of worse outcomes in women (vs. men) after elective abdominal aortic aneurysm repair has not ameliorated with time and the risk ratio for mortality is higher for EVAR than open repair. Sex specific differences varied with type of repair, allowing insight into the increased mortality risk differential for EVAR. Better pre-operative optimisation might reduce the higher risk of systemic complications in women. Arterial injury, renal, and other ischaemic complications (limb and bowel ischaemia), which probably contribute to mortality, are higher in women, especially after EVAR, and may be avoidable with strategic planning.Objective: Previously, reports have shown that women experience a higher mortality rate than men after elective open (OAR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With recent improvements in overall AAA repair outcomes, this study aimed to identify whether sex specific disparity has been ameliorated by modern practice, and to define sex specific differences in peri-and post-operative complications and preoperative status; factors which may contribute to poor outcome. Methods: This was a systematic review, meta-analysis, and meta-regression of sex specific differences in 30 day mortality and complications conducted according to PRISMA guidance (Prospero registration CRD42020176398). Papers with ! 50 women, reporting sex specific outcomes, following intact primary AAA repair, from 2000 to 2020 worldwide were included; with separate analyses for EVAR and OAR. Data sources were Medline, Embase, and CENTRAL databases 2005 e 2020 searched using ProQuest Dialog. Results: Twenty-six studies (371 215 men, 65 465 women) were included. Meta-analysis and meta-regression indicated that sex specific odds ratios (ORs) for 30 day mortality were unchanged from 2000 to 2020. Mortality risk was higher in women for OAR and more so for EVAR (OR [95% CI] 1.49 [1.37 e 1.61]; 1.86 [1.59 e 2.17], respectively) and this remained following multivariable risk adjustment. Transfusion, pulmonary complications, and bowel ischaemia were more common in women after OAR and EVAR (OAR:

Studies Related to Ruptured Abdominal Aortic Aneurysms in the Past 10 Years (2011-2020): A Bibliometric Analysis

“…In addition, according to Figure 6B , while clinically relevant studies continue to progress, they are being refined to focus on the heterogeneity of different populations, such as octogenarians [ 49 ] and women. Among them, women with AAA rupture have a higher risk of death after EVAR or OR [ 50 ]. New research methods like geometric-biomechanical [ 51 ] and computational mathematics models [ 52 ] are also involved, which can be used to predict AAA rupture, including the assessment of elastic and fluid characteristics, and may provide some value for AAA growth and rupture.…”

Systematic Reviews of the Literature Are Not Always Either Useful Or the Best Way To Add To Science

“…An example here is the recent updating of a 2010 systematic review evaluating the sex specific operative mortality from intact abdominal aortic aneurysm repair, given the advances in both endograft and imaging technology. 6 , 7 To investigate how factors such as age, sex, ethnicity, and frailty influence clinical outcomes using evidence from both RCTs and observational studies, for example, the influence of age, sex, and contralateral occlusion on stroke and death after carotid endarterectomy or carotid stenting. 8 Presentation of sensitivity analyses to compare information obtained from RCTs vs. observational studies may be illuminating.…”

“…An example here is the recent updating of a 2010 systematic review evaluating the sex specific operative mortality from intact abdominal aortic aneurysm repair, given the advances in both endograft and imaging technology. 6 , 7 …”

Identifying Women at High Risk of 90 Day Death after Elective Open Abdominal Aortic Aneurysm Repair: A Multicentre Case Control Study

“…A recent meta-analysis of 13 observational studies found an increased risk of death after open surgical repair (OSR) of abdominal aortic aneurysm (AAA) in women vs. men (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.37–1.61). 1 Even after multivariable adjustment for risk factors, female sex is associated with higher peri-operative mortality. 2 , 3 , 4 It has been suggested that differences in the recognition of pre-operative risk or complications may account for the increased mortality, yet it is largely unexplained.…”

“… 2 , 3 , 4 It has been suggested that differences in the recognition of pre-operative risk or complications may account for the increased mortality, yet it is largely unexplained. 1 In a systematic review comparing baseline comorbidity between women and men undergoing elective OSR for AAA, it was found that women were significantly older at the time of surgery and had diabetes and ischaemic heart disease less often. 5 As the prevalence of AAA is much higher in men than women, the current knowledge of risk factors may be primarily applicable to men.…”