Female Sex is a Marker for Higher Morbidity and Mortality after Elective Endovascular Aortic Aneurysm Repair: A National Surgical Quality Improvement Program Analysis

Presentation and outcomes of thoracic and thoracoabdominal aortic aneurysms in females, existing gaps, and future directions: A descriptive review

Thoracic and thoracoabdominal aortic aneurysms are more common in men. Yet, females often have worse outcomes, fewer interventions, and lower treatment rates. Females have also benefited less from the research and treatment of those diseases than men. Understanding sex- and sex-specific differences in thoracic and thoracoabdominal aortic aneurysms can improve care delivery, reduce disparities, and optimize outcomes for females with thoracic aortic aneurysms and thoracoabdominal aortic aneurysms. The authors reviewed the literature on the presentation and outcomes of thoracic and thoracoabdominal aortic aneurysms in females, discussing the existing gaps and future directions to address them.

Three-Year Safety and Efficacy of the INCRAFT Endograft for Treatment of Abdominal Aortic Aneurysms: Results of the INSIGHT Study

PURPOSE

Preliminary results of the INSIGHT study showed that the low-profile INCRAFT Abdominal Aortic Aneurysm (AAA) Stent-Graft System was safe and effective in the endovascular aneurysm repair (EVAR). This study aimed to assess the durability and the midterm effectiveness of EVAR using the INCRAFT System in the framework of a multicenter, prospective, open-label, post-approval study.

MATERIALS AND METHODS

Between 2015 and 2016, 150 subjects from 23 European centers treated with the INCRAFT System for an infrarenal AAA were included. Clinical and radiologic data were prospectively collected and analyzed using protocol-specified, monitored follow-up clinic visits at 1, 6, and 12 months post-implantation and annually after that. The clinical success at 3 years was determined. Freedom from overall and aneurysm-related mortality, type I endoleak, secondary interventions, and aneurysm sac enlargement through 3 years were evaluated. Kaplan-Meier estimates were used for late outcomes. An independent clinical events committee reviewed all events. The CT (computed tomography) scans through 1 year were reviewed by an independent core laboratory.

RESULTS

The primary clinical success rate at 3 years was 84.0% (126/150). There were no aneurysm-related deaths, endograft migration, or aneurysm-related ruptures through 3 years. Stent fracture was detected in 2 subjects (1.3%) without clinical sequelae. Over 3 years, freedom from overall mortality was 89.4%, freedom from secondary interventions was 80%, and freedom from aneurysm sac enlargement was 96.5%. The 3-year freedom from type IA and IB endoleaks was 93.3% and 98.6%, respectively.

CONCLUSIONS.

In a multicenter real-world study setting, the use of a low-profile INCRAFT device for AAA is associated with sustained clinical success and low rates of reinterventions through 3 years.

CLINICAL IMPACT

Low-profile endografts have broadened the spectrum of patients with anatomic suitability for endovascular repair of abdominal aortic aneurysms (AAA). However, questions remain regarding the durability of the repair. The INSIGHT study evaluated the use of the INCRAFT System in routine real-world clinical practice, including patients with complex anatomies. The treatment was safe and effective. The results showed sustained clinical success over 3 years, with no aneurysm-related deaths or ruptures, and a high rate of intervention-free survival at 3 years. Despite the low-profile design of the endograft, the midterm results demonstrate the durability of AAA repair using the INCRAFT System.ClinicalTrials.gov Identifier: NCT02477111.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

Sex-Comparative Outcomes of the T-Branch Device for the Treatment of Complex Aortic Aneurysms

INTRODUCTION

Females are at increased risk of mortality compared to males after complex endovascular aortic repair. This study aims to examine sex-related peri-operative and follow-up outcomes in patients managed with the t-Branch device.

METHODS

A two-center retrospective analysis of patients managed with the off-the-shelf t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) between 1 January 2014 and 30 September 2020 was performed. Primary outcomes were sex-comparative 30-day mortality, major adverse events (MAEs) and spinal cord ischemia (SCI).

RESULTS

A total of 542 patients were included; 28.0% were females. Urgent repair and type I-III thoracoabdominal aneurysms were more common among females (52.6% vs. 34%, p = 0.01, and 57.1% vs. 35.8%, p = 0.004). Technical success was similar (97.4% vs. 96.9%, p = 0.755), as well as early mortality (16.2% in females vs. 10.8% in males; p = 0.084). SCI rates were similar between groups (13.6% vs. 9.2% p = 0.183). MAEs were more common in females; 33.7% vs. 21.4% (p = 0.022). Multivariate analysis did not identify sex as an independent predictor of adverse events. The 12-month survival rate was 75.7% (SE 0.045) for females and 84.1% (SE 0.026) for males (log rank, p = 0.10).

CONCLUSIONS

Sex was not detected as an independent factor of mortality, MAEs and SCI within patients managed with the t-Branch device. Feasibility was high in both groups. No significant difference was shown in survival during the 12-month follow-up.

Early and Mid-Term Outcomes of Females Treated with t-Branch off the Shelf Device

BACKGROUND

Female sex has been characterized as a risk factor of increased mortality in patients managed for complex aortic aneurysm using endovascular means. This study aimed to present the perioperative and follow-up outcomes of females managed electively or urgently with the t-Branch device and investigate factors affecting the early outcomes.

METHODS

A 2-center retrospective observational study was conducted including elective and urgent female patients managed with the t-Branch device (Cook Medical, Bjaeverskov, Denmark) for thoracoabdominal and pararenal aneurysms between January 1, 2018 and September 30, 2020. Primary early outcomes included technical success and 30-day mortality and morbidity [spinal cord ischemia (SCI) and acute kidney injury]. Follow-up survival and freedom from reintervention rates were assessed using Kaplan-Meier estimates.

RESULTS

In total, 153 females were included; 81 (52.9%) treated urgently. Urgent patients were older (73.2 ± 8.6 vs. 68.5 ± 6.8 years; P < 0.001) and presented higher previous coronary angioplasty/stenting (16.0% vs. 5.6%, P = 0.005) and lower double antiplatelet therapy (DAPT, 46.3% vs. 53.7%, P = 0.04) rates. Technical success was 97.4%. Early mortality was 16.3% (22% in urgent; 12% in elective; P = 0.2) and SCI and acute kidney injury were diagnosed in 13.7% (11% in urgent; 16% in elective; P = 0.2) and 18.3% (22.2% in urgent; 13.9% in elective; P = 0.18), respectively. Multivariate regression analyses showed that DAPT and b-blockers were related to lower 30-day mortality. DAPT was also preventive for SCI. Survival rates were 68.4% [standard error (SE) 0.07] at 12 months for the urgent and 75.6% (SE 0.09) at 24 months for the elective group (P = 0.14). Freedom from reintervention rates were 81.4% (SE 0.06) at 6 months and 64.7% (SE 0.09) at 18 months for the urgent and 81.7% (SE 0.06) at 6 months and 75.4% (SE 0.081) at 18 months for the elective group (P = 0.94).

CONCLUSIONS

Female patients managed with the t-Branch device for thoracoabdominal and pararenal aneurysms in elective and urgent setting presented similar 30-day mortality and SCI rates.

Sex Related Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

OBJECTIVE

Current literature suggests that thoracic endovascular aortic repair (TEVAR) in older patients with aortic aneurysms results in higher peri-operative mortality and lower long term survival in females compared with males. However, sex related outcomes in younger patients with blunt thoracic aortic injury (BTAI) undergoing TEVAR remain unknown. This study examined the association between sex and outcomes after TEVAR for BTAI.

METHODS

A retrospective cohort study was performed of all patients who underwent TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2016 and 2019. The primary outcome was in hospital death. Secondary outcomes were peri-operative complications. Multivariable logistic regression was used to adjust for demographics, comorbidities, injury severity score, and aortic injury grade.

RESULTS

Two thousand and twenty-two patients were included; 26% were female. Compared with males, females were older (46 [IQR 30, 62] vs. 39 [IQR 28, 56] years; p < .001), more often obese (41% vs. 33%; p = .005), had lower rates of alcohol use disorder (4.1% vs. 8.9%; p < .001) and a higher prevalence of hypertension (29% vs. 22%; p = .001). The injury severity was comparable between females and males (Injury Severity Score ≥ 25; 84% vs. 80%; p = .11) and there was no difference in aortic injury grades when comparing females with males (grade 1, 33% vs. 33%; grade 2, 24% vs. 25%; grade 3, 43% vs. 40%; grade 4, 0.8% vs. 1.3%; p = .53). Multivariable logistic regression demonstrated no difference for in hospital mortality between females and males (OR 1.02; 95% CI 0.67 - 1.53, p = .93). Compared with males, females were at lower risk of acute kidney injury (AKI) (OR 0.33; 95% CI 0.17 - 0.64; p = .001) and ventilator associated pneumonia (VAP) (OR 0.50; 95% CI 0.28 - 0.91; p = .023).

CONCLUSION

This study did not demonstrate a sex related in hospital mortality difference following TEVAR for BTAI. However, female sex was associated with a lower risk of AKI and VAP. Future studies should evaluate sex differences and long term outcomes following TEVAR in patients with BTAI.

Comprehensive Evaluation of Common Open and Endovascular Procedures and Their Relationship with Postdischarge Complications

BACKGROUND

Percutaneous endovascular treatment for arterial vascular diseases has revolutionized vascular care. While these procedures offer improved morbidity, mortality, and length of stay (LOS), their effect on postdischarge complications is unknown. The objectives of the study were to evaluate trends in LOS and postdischarge complications over time and to assess factors associated with postdischarge complications.

METHODS

Patients who underwent surgery for common vascular pathologies (abdominal aortic aneurysm, aortoiliac occlusive disease, lower extremity disease, and carotid stenosis) were identified from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted database (2014-2019). Outcomes included LOS, 30-day complications, and proportions of postdischarge complications. Predictors of postdischarge complications were assessed using a multivariable logistic regression.

RESULTS

Of 80,311 patients evaluated, median LOS did not change from 2014 to 2019 (2, interquartile range 1-5). Overall, 15.7% of patients experienced any 30-day complication, with 31.3% occurring after discharge. The proportion of postdischarge complications increased from 29.1% (2014) to 35.9% (2019), P < 0.001. With exception of carotid procedures, endovascular procedures had lower overall complication rates than open procedures; however, there was an increased proportion of postdischarge complications for endovascular procedures (all P < 0.001). Factors associated with an increased odds of postdischarge complications included female, Black or other race, dependent functional status, underweight or obesity, increased LOS, and procedural time, all P < 0.05.

CONCLUSIONS

Across 4 representative common vascular pathologies, endovascular treatments had a higher proportion of postdischarge complications compared to open procedures. Early identification and evaluation of postdischarge complications for endovascular patients may be warranted to avoid unplanned readmission.

Racial disparities in presentation and outcomes for endovascular abdominal aortic aneurysm repair

OBJECTIVE

In the present study, we used a national database to identify racial differences in the presentation and outcomes for patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (EVAR) and identified areas for improving their care.

METHODS

We queried the EVAR-targeted National Surgical Quality Improvement Program database (2016-2019) to identify patients who had undergone EVAR for both ruptured and nonruptured AAAs. The patients were categorized according to race (White, Black, and Asian). Patients with a history of abdominal aortic surgery or an indication other than AAAs were excluded. The data was analyzed using the χ² and Kruskal-Wallis tests, presented as frequencies and percentages or median and interquartile range (IQR) for categorical and continuous variables, respectively.

RESULTS

We identified 3629 patients (16.6% female), including 3312 White (91.3%), 248 Black (6.8%), and 69 Asian (1.9%) patients. Black patients were more frequently women (27.0%) compared with White patients (15.9%) and were younger (median age, 71 years; IQR, 64-77 years) than White (median age, 73 years; IQR, 67-79 years) and Asian (median age, 76 years; IQR, 67-81 years) patients (P < .001 for both). The incidence of smoking, congestive heart failure, and dialysis dependency was highest for Black patients, and the incidence of obesity was lowest for Asian patients. The AAAs in Black patients extended more frequently beyond the aortic bifurcation (P = .047). In Asian patients, the internal iliac arteries were more involved (P = .040). For Black patients, 29.8% of the EVARs were performed in a nonelective setting compared with 20.2% for the White and 15.9% for the Asian patients (P < .001). The aneurysm diameter, nonruptured symptomatic rate, and rupture rate were similar across the groups (P = .807). The operative time was prolonged for Black (median, 128 minutes; IQR, 96-177 minutes) compared with White (median, 114 minutes; IQR, 84-162 minutes) patients (P < .001). Postoperatively, Black patients were more likely to require blood transfusion (16.5%) and had prolonged length of hospital stay (median, 2 days; IQR, 1-4 days) compared with White (10.0%; median, 1 day; IQR, 1-3 days) and Asian (4.3%; median, 1 day; IQR, 1-3 days) patients (P = .001 and P < .001, respectively). Black patients also had a higher 30-day readmission rate (P = .038). On multivariate analysis, Black race was an independent factor for length of stay >1 day after both elective and nonelective EVAR and 30-day readmission for elective EVAR, but not 30-day mortality after elective and nonelective EVAR.

CONCLUSIONS

In the present nationwide sample of EVAR cases, Black patients were more often women and younger. Despite similar rates of symptomatic and ruptured AAAs at presentation and 30-day mortality, Black patients more often presented and were treated during the same nonelective admission; they also had associated increased length of hospital stay and readmission. These findings signal a missed opportunity to diagnose, optimize, and treat this particular group of patients in an elective setting.

The Effect of Smoking Status on Perioperative Morbidity and Mortality after Open and Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVES

This study quantifies the extent to which active tobacco smoking is deleterious towards outcomes following open and endovascular AAA repair.

METHODS

Open and endovascular abdominal aortic aneurysm (AAA) repairs between January 2003 and June 2020 in the Vascular Quality Initiative (VQI) were queried. Rupture, symptomatic status, and lack of 90 day follow up were exclusions. Patients were then placed into one of six groups : open AAA with active smoking (n=3788); open AAA with prior smoking (n=4614); open AAA never smokers (817); endovascular AAA active smokers (n=14173); endovascular AAA former smokers (n=25,831); and, endovascular AAA never smokers (n=6064). Comparison of baseline characteristics, co-morbidities, and adverse outcomes across each of the 6 cohorts was performed with open AAA in active smokers serving as the reference. Sub-analysis investigating open AAA repair in active smokers relative to open AAA in patients confirmed in VQI to have quit smoking between 30 and 90 days before surgery was performed. Smoking cessation for a minimum of 30 days before surgery was required to fall into the former smoker category.

RESULTS

In comparing open AAA in active smokers to open AAA in former and never smokers, the active smokers experienced significantly higher rates of pneumonia (P<.001). Combined additive morbidity and mortality was highest (54%) in active smokers (P<.001 relative to all cohorts other than open AAA former smokers P=.21). Smoking status did not impact morbidity or mortality incidence across individuals undergoing EVAR. Binary logistic regression for all AAA patients (open and endovascular combined) revealed those with any history of smoking to be more likely to experience 90 day mortality (adjusted OR 2.5 (2.2-2.9), P<.001) relative to never-smokers. Active smokers were similarly more likely to experience 90 day mortality than prior/never smokers combined (OR 1.23 (1.07-1.38), P<.001). Mortality within 90 days was significantly more likely (P<.001) with aging, female gender, larger aneurysms, preoperative history of congestive heart failure, chronic obstructive pulmonary disease, chronic renal insufficiency, peripheral artery disease, body mass index under 20 and over 35 mg/kg². Diabetes and coronary artery disease were also associated with 90 day mortality (P= .045 and .049 respectively). Quitting smoking between 30 and 90 days before open repair reduced combined additive morbidity and mortality relative to active smokers (OR 1.34, P =.038).

CONCLUSIONS

Smoking cessation 30 days before open AAA repair reduces perioperative morbidity and mortality. Smoking status does not impact morbidity and mortality in patients undergoing endovascular AAA repair. When combining all patients (open and endovascular), higher rates of 90 day mortality are associated with any history of smoking, aging, female gender and advanced pre-existing co-morbidities on multivariable analysis.

Radiocephalic Arteriovenous Fistula Patency and Use

We sought to confirm and extend the understanding of clinical outcomes following creation of a common distal autogenous access, the radiocephalic arteriovenous fistula (RCAVF).

Mini-abstract: In this post hoc analysis of randomized clinical trial data including 914 adults with chronic kidney disease, the most robust predictors of radiocephalic arteriovenous fistula patency were larger cephalic vein diameter and access creation prior to a chronic hemodialysis requirement. Successful use occurred at increased rates in men, patients with larger diameter cephalic veins, smaller diameter arteries (albeit ≥2 mm), and when accesses were created using regional anesthesia and at higher volume centers.

One-Year Results of the INSIGHT Study on Endovascular Treatment of Abdominal Aortic Aneurysms

OBJECTIVE

Endovascular repair of abdominal aortic aneurysms (AAA) using the INCRAFT™ AAA Stent Graft System was safe and effective in regulatory approval studies. We herein report on the 1-year results of a real-world clinical study.

METHODS

The INSIGHT study is a multi-center, prospective, open label, post-approval study conducted to continually evaluate the safety and performance of the INCRAFT ™ System. Between 2015 and 2016, 150 consecutive patients with AAA at 23 centers in Europe were treated with the device in routine clinical practice. The primary endpoint was freedom from major adverse events (MAEs), namely death, myocardial infarction (MI), cerebrovascular accident (CVA) and renal failure, within 30 days of the index procedure. Endpoint data were assessed by a core laboratory. The secondary endpoints included technical success at the conclusion of the procedure and clinical success.

RESULTS

All 150 patients studied (mean age: 73.6 ± 8.0 and 89.3% men) met the primary endpoint without MAEs at 30-day follow up. Technical success was achieved in 99.3% of patients without stent fractures at 30 days. Among the 146 patients eligible for 1-year follow-up, the MAE rate was 8.2%, i.e., 12 patients suffered 13 MAEs: CVA in 8, MI in 1, and 4 died (resulting in a 2.7% all-cause mortality rate). There were no reports of new onset renal failure requiring dialysis. Only 2.7% of patients had type I endoleak and no III endoleaks were identified through 1 year. The rate of clinical success at 1 year was 91.8%.

CONCLUSIONS

The 1-year results of this multicenter real-world study underscore the safety and effectiveness of endovascular treatment of AAA with the INCRAFT System in routine clinical practice.

Proximal fixation of endovascular aortic device may not be associated with renal function decline after abdominal aortic aneurysm repair

OBJECTIVE

Significant debate exists among providers who perform endovascular abdominal aortic aneurysm repair (EVAR) regarding the renal function change between suprarenal (SuF) and infrarenal (InF) fixation devices. The purpose of this study is to review our institution's experience using these devices in terms of renal function.

METHODS

This is a retrospective review of all elective EVARs performed within a three-site health system (Florida, Minnesota, and Arizona) during the period of 2000 to 2018. The primary outcome was renal function decline on long-term follow-up depending on the anatomical fixation of the device (SuF vs InF). Secondary outcomes were length of hospitalization (LOH) and progression to hemodialysis. Multivariable regression analysis was performed to test for associations affecting LOH.

RESULTS

There were 1130 elective EVARs included in our review. Of those, 670 (59.3%) had SuF and 460 (40.7%) InF. Long-term follow-up was 4.8 ± 3.7 years, and the rate of change in creatinine and estimated glomerular filtration rate (eGFR) were not statistically significant among groups (SuF vs InF). LOH was higher in those individuals with a SuF device (3.4 ± 2.2 vs 2.3 ± 1.0 days; P < .001). Ten patients with chronic kidney disease progressed to hemodialysis at 6.7 ± 3.8 years from EVAR. On Kaplan-Meier analysis, patients with chronic kidney disease with SuF were more likely to progress to hemodialysis (P = .039). On multivariable regression, female sex (Coef, 2.4; 95% confidence interval [CI], 0.17-0.41; P = .02), SuF (Coef, 9.5; 95% CI, 0.11-1.11; P < .0001), and intraoperative blood loss of greater than 150 mL (Coef, 15.4; 95% CI, 0.11-1.76; P < .0001) were predictors of prolonged LOH.

CONCLUSION

Our three-site, single-institution data indicate that, although the starting eGFR was statistically lower in those individuals undergoing elective EVAR with InF, device fixation type did not affect the creatinine and eGFR on long-term follow-up. However, caution should be exercised at the time of abdominal aortic aneurysm repair in those individuals who already presented with renal dysfunction.

Differences in Comorbidities Between Women and Men Treated with Elective Repair for Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis

OBJECTIVES

Elective abdominal aortic aneurysm (AAA) repair is performed to prevent rupture. For reasons as yet unknown, the 30-day mortality risk after elective AAA repair is higher in women than in men. We hypothesised that this higher risk might be related to differences in comorbidity.

METHODS

Systematic review (PROSPERO CRD42019133314) according to PRISMA guidelines. A search in the EMBASE/MEDLINE/CENTRAL databases identified 1870 studies that included patients who underwent elective AAA repair (final search February 17^th, 2021). Ultimately, 28 studies were included and all reported comorbidities were categorised into 17 comorbidity groups. Additionally, 15 groups of clearly defined comorbidities were used for sensitivity analysis. For both groups, meta-analyses of each comorbidity were performed to estimate the difference in pooled prevalence between women and men with a random effects model.

RESULTS

When analysing data of all reported comorbidities (17 groups), smoking [risk difference (RD) 11%, 95% confidence interval (CI) 4-18], diabetes (RD 3%, 95% CI 2-4), ischaemic heart disease (RD 12%, 95% CI 8-16), arrhythmia (RD 3%, 95% CI 0.4-5), liver disease (RD 0.1%, 95% CI 0.01-0.2), and cancer (RD 3%, 95% CI 2-4)) were less prevalent in women, whereas, hypertension (RD 4%, 95% CI 3-6) and pulmonary disease (RD 4%, 95% CI 3-5) were more prevalent in women. At the time of surgery women were significantly older than men (74.9 years versus 72.4; mean difference 2.4 years (95% CI 2.1-2.7)). In the sensitivity analysis of 15 comorbidity groups, the same comorbidities remained significantly different between women and men, except smoking and arrhythmia. Women had a higher mortality risk than men (RD 1%, 95% CI 1-2).

CONCLUSIONS

Although women undergoing elective AAA repair have fewer baseline comorbidities than men, their 30-day mortality risk is higher. In-depth studies on the cause of death in women after elective AAA repair are needed to explain this discrepancy in mortality.

Women have similar mortality but higher morbidity than men after elective endovascular abdominal aortic aneurysm repair

OBJECTIVE

Sex disparities regarding outcomes for women after open and endovascular abdominal aortic aneurysm repair have been well-documented. The purpose of this study was to review whether these disparities were also present at our institution for elective endovascular aneurysm repair (EVAR) and whether specific factors predispose female patients to negative outcomes.

METHODS

All elective EVARs were identified from our three sites (Florida, Minnesota, and Arizona) from 2000 to 2018. The primary outcome was in-hospital mortality and three-year mortality. Secondary outcomes included complications requiring return to the operating room, length of hospitalization (LOH), intensive care unit (ICU) days, and location of discharge after hospitalization. Multivariable logistic regression models were used to assess for the risk of complications.

RESULTS

There were 1986 EVARs; 1754 (88.3%) were performed in male and 232 (11.7%) in female patients. Female patients were older (79 years [interquartile range (IQR), 72-83 years] vs 76 years [IQR, 70-81 years]; P < .001), had a lower body mass index (median, 26.1 kg/m² [IQR, 22.1-31.0 kg/m²] vs 28.3 kg/m² [IQR, 25.3-31.6 kg/m²]; P < .001 and hematocrit (median, 37.6% [IQR, 33.4%-40.6%] vs 39.4% [IQR, 35.6%-42.6%]; P < .001) and had higher glomerular filtration rate (median, 84.4 mL/min per 1.73m² [IQR, 62.3-103 mL/min/1.73 m²] vs 51.1 mL/min/1.73 m² [IQR, 41.8-60.8 mL/min/1.73 m²]; P < .001. Female patients were also more likely to be active smokers (15.3% vs 13.1%; P < .001) and have chronic obstructive pulmonary disease (24.7% vs 15.3%; P = .001). They were less likely to have coronary artery disease (31.6% vs 45.6%; P < .001). Aneurysms in women were slightly smaller in size (median, 54 mm [IQR, 50.0-58.0 mm] vs 55 mm [IQR, 51.0-60.0 mm]; P = .004). In-hospital mortality and mortality at the 3-year follow-up was not significant between female and male patients (0.86% vs 0.17%; P = .11 and 38.4% vs 36.2%; P = .57). However, female patients returned to the operating room with a greater frequency than male patients (3.9% vs 1.4%; P = .011). LOH (mean, 3.4 ± 3.8 days vs 2.5 ± 2.4 days; P < .001) and ICU days (mean, 0.3 ± 2.0 days vs 0.1 ± 0.5 days; P < .001) were longer for female patients. After hospitalization, female patients were discharged to rehabilitation facilities in greater proportion (12.7% vs 3.1%; P < .001) than their male counterparts. On multivariable analysis, female sex was associated with a return to the operating room (odds ratio, 6.4; 95% confidence interval [CI], 1.4-3.5; P = .02), longer LOH (Coef 4.0; 95% CI, 1.0-2.5; P = .00007), more ICU days (Coef 2.8; 95% CI, 1.1-3.0; P = .005), and a greater likelihood of posthospitalization rehabilitation facility placement (odds ratio, 5.8; 95% CI, 1.5-2.4; P = .0001).

CONCLUSIONS

Our three-site, single-institution data support sex disparities to the detriment of female patients regarding return to the operating room after EVAR, LOH, ICU days, and discharge to rehabilitation facility. However, we found no differences for in-hospital or 3-year mortality.