A single-centre study of standard, fenestrated and branched endovascular aneurysm repair patients in Nürnberg, Germany, has found that outcomes for women are worse but the reasons are not yet clear, as literature on the topic is lacking. The results and literature review of gender differences in treating abdominal aortic aneurysm were presented by Athanasios Katsargyris (Klinikum Nürnberg, Germany) at the 23rd annual Critical Issues symposium (23–24 May, Liverpool, UK).
Katsargyris began with an overview of previous studies that have examined the difference in outcomes for female aneurysm patients receiving endovascular aneurysm repair (EVAR). In a UK-based study by D Lowry and colleagues, published in the European Journal of Vascular and Endovascular Surgery in 2016, data from a large cohort showed some “clear differences” in comparing the approximately 11% of patients who were women to the rest of the cohort. “Women were older at presentation of aneurysm, compared to male patients,” Kastargyris said. “They had a longer hospital stay, 30-day mortality and 30-day readmission rates were higher, and finally, survival through to one year was also better for men compared to women.” A second study from Sarah Deery et al, published in 2017 in the Journal of Vascular Surgery, similarly examined a large cohort of EVAR patients to identify differences in outcome for men versus women, finding that women were “at higher risk for 30-day death and major complications after intact abdominal aortic aneurysm repair”. Again, Katsargyris drew attention to the older age of female EVAR patients in this cohort. Another finding identified in current literature, Katsargyris noted, is that “women more often have a hostile anatomy, and will more often receive EVAR outside of instructions for use”. Lastly, Katsargyris pointed to the notable SWAN study by Janet Powell et al, which examined approximately 52,000 men and 11,000 women, “we saw again here that women present with higher 30-day mortality—but what was also reported here was that women were less often eligible for EVAR, and for this reason the authors concluded that management of abdominal aortic aneurysm for women needs improvement urgently.”
As for complex EVAR of fenestrated EVAR (FEVAR), Katsargyris explained he had not found many publications yet available on this topic. Only one paper known to him, authored in 2016 by David Timaran et al in the Journal of Vascular Surgery, had examined gender-related outcomes for a group of 79 thoracoabdominal endovascular aortic repairs (TEVARs), which again found worse outcomes for female patients.
“If we put all this together,” said Katsargyris, “it seems indeed as though women present with inferior outcomes compared to men, and there are some potential reasons observable in the literature here.” However, he maintained that despite the indication that women are older compared to men, presenting more often with hostile anatomy and therefore treated more often outside instructions for use, and also need more procedures, “it seems there are other factors here that need to be investigated and clarified.”
“After all,” he explained, “even if we try to take out and control for all potential confounding factors, we see that still, female gender appears to remain an independent negative prognostic factor for outcomes.”
At Klinikum Nürnberg, Katsargyris and colleagues collected data for three different patient types of procedures performed between 2010 and 2018: standard EVAR (442 elective patients with 399 men [90.3%] and 43 women [9.7%]), FEVAR ( 454 patients, 412 men [90.7%] vs. 42 women [9.3%]), and branched EVAR (BEVAR; 377 patients, 295 men [78.2%] vs. 82 women [21.8%]). Although no significant differences could be found between male and female outcomes in the EVAR and FEVAR groups, Katsargyris drew attention to the BEVAR cohort, which also had a higher percentage of women: “In this group, we could not find any difference with regards to anatomical risk factors, however, looking at the early outcomes we could see that 30-day mortality was higher for women at 12% versus 5.8% for men.” This was found despite the fact that both groups had equal technical success rate out of the overall 95% success rate. Moreover, Katsargyris reported that no significant difference was found in 30-day major complications that could offer an explanation for this mortality discrepancy. Overall, Katsargyris noted that more investigation is needed, as literature on the topic is “scarce” for FEVAR, and “non-existent” for BEVAR.