Female sex independently predicts mortality after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms

Abstract

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.

Editor's Choice – Sex Specific Differences in the Management of Descending Thoracic Aortic Aneurysms: Systematic Review with Meta-Analysis

“…The quality score ranged from five to nine with the observational non-population based studies yielding the lowest quality scores, 16e18 while the four population based studies had scores closer to the maximum. 7,15,19,22 The characteristics of all the included studies are summarised in Table 2.…”

“…There were four population based studies: two from the USA covering different time periods, 7,15 one from the UK, 22 and one from Germany, 19 contributing a total of 2441 women and 4193 men. Other studies from the USA from a single centre and two multicentre clinical trials provided 317 women and 481 men.…”

“…Four studies were eligible for sensitivity analysis of a combined outcome, including stroke and spinal cord ischaemia events. 16e19 Two others, 7,15 including the large US study, 7 were excluded owing to missing information on spinal cord ischaemia events. Pooled neurological event rates of these four studies provided similar results, with no sex specific differences following TEVAR (OR 0.80, 95% CI 0.39e…”

“…Arnaoutakis et al, 2014 15 Deery et al, 2017 7 Jackson et al, 2017 16 Kasirajan et al, 2011 17 Von Allmen et al, Ranney et al, 2018 Fixed effect model Random effects model Heterogeneity: I 2 = 0%, W 2 = 0, p = .87 Figure 2. Forest plot of 30 day mortality after thoracic endovascular aneurysm repair for descending thoracic aortic aneurysm for women vs. men.…”

“…3e6 Recent analysis of the Vascular Quality Initiative data of the Society for Vascular Surgery has suggested that women have worse outcomes than men after TEVAR for descending TAAs. 7 However, it is not clear whether these observations either apply to open repair or can be generalised. A recent narrative review of sex differences in mortality after TEVAR was not restricted to descending TAAs, but did note the tendency for women to have a higher 30 day mortality than men.…”