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Preventza O, Akpan-Smart E, Simpson KK, Cornwell LD, Amarasekara H, Green SY, Chatterjee S, LeMaire SA, Coselli JS. The intersection of community socioeconomic factors with gender on outcomes after thoracic aortic surgery. J Thorac Cardiovasc Surg 2023; 166:1572-1582.e10. [PMID: 36396474 DOI: 10.1016/j.jtcvs.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/23/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We evaluated the relationship among community socioeconomic factors (poverty, income, and education), gender, and outcomes in patients who underwent ascending aortic, root, and arch surgery. METHODS For 2634 consecutive patients, we associated patients' ZIP codes with community socioeconomic factors. The composite adverse outcome comprised death, persistent neurological injury, and renal failure necessitating dialysis at discharge. Multivariable analysis and Kaplan-Meier survival curves were used. Men and women from the full cohort and from the elective patients were propensity matched. RESULTS Median follow-up was 3.6 years (interquartile range, 1.2-9.3). Men lived in areas characterized by less poverty (P = .03), higher household income (P = .01), and more education (P = .02) than women; likewise, in the elective cohort, all community socioeconomic factors favored men (P ≤ .009). Female gender predicted composite adverse outcome (P = .006). In the propensity-matched women and men (820 pairs), the composite adverse outcome rates were 14.2% and 11%, respectively (P = .06). In 583 propensity-matched pairs of elective patients, men had less composite adverse outcome (P = .02), operative mortality (P = .04), and renal (P = .02) and respiratory failure (P = .0006). The 5- and 10-year survivals for these men and women were 74.2% versus 71.4% and 50.2% versus 48.2%, respectively (P = .06). All community socioeconomic factors in both propensity-matched groups nonsignificantly favored men. CONCLUSIONS This study is among the first to examine the association among community socioeconomic factors, gender, and outcomes in patients who undergo proximal aortic surgery. Female gender predicted a composite adverse outcome. In the elective patients, most adverse outcomes were significantly less in men. In the propensity-matched patients, all community socioeconomic factors favored men, although not significantly. Larger studies with patient-level socioeconomic information are needed.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
| | | | - Katherine K Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
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2
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Kiang SC, Lee MM, Dakour-Aridi H, Hassan M, Afifi RO. Presentation and outcomes of thoracic and thoracoabdominal aortic aneurysms in females, existing gaps, and future directions: A descriptive review. Semin Vasc Surg 2023; 36:501-507. [PMID: 38030324 DOI: 10.1053/j.semvascsurg.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
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.
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Affiliation(s)
- Sharon C Kiang
- Vascular Division, Department of Surgery, Loma Linda Veterans Healthcare System, Loma Linda, CA
| | - Mary M Lee
- Vascular Division, Department of Surgery, Loma Linda Veterans Healthcare System, Loma Linda, CA
| | - Hanaa Dakour-Aridi
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Madiha Hassan
- McGovern Medical School at UTHealth Houston, 6400 Fannin Street, Suite 2850, Houston, TX, 77030
| | - Rana O Afifi
- McGovern Medical School at UTHealth Houston, 6400 Fannin Street, Suite 2850, Houston, TX, 77030.
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3
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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4
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Benk J, Berger T, Kondov S, D'Inka M, Bork M, Walter T, Discher P, Rylski B, Czerny M, Kreibich M. Comparative Study of Male and Female Patients Undergoing Frozen Elephant Trunk Total Arch Replacement. J Clin Med 2023; 12:6327. [PMID: 37834975 PMCID: PMC10573986 DOI: 10.3390/jcm12196327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Our aim was to investigate outcomes and long-term survival in male and female patients after frozen elephant trunk (FET) total arch replacement. METHODS Between March 2013 and January 2023, 362 patients underwent aortic arch replacement via the FET technique. We compared patient characteristics and intra- and postoperative data between male and female patients. RESULTS Male patients were significantly younger (p = 0.012) but revealed a higher incidence of coronary artery disease (p = 0.008) and preoperative dialysis (p = 0.017). More male patients presented with type A aortic dissections (p = 0.042) while more female patients had aortic aneurysms (p = 0.025). The aortic root was replaced in significantly more male patients (p = 0.013), resulting in significantly longer cardiopulmonary bypass duration (p < 0.001) and operative times (p < 0.001). There were no statistically significant differences in postoperative outcome parameters including in-hospital mortality (p = 0.346). However, new in-stent thrombus formation was significantly more frequent in female patients (p = 0.002). Age in years (odds ratio (OR): 1.026, p = 0.049), an acute pathology (OR: 1.941, p = 0.031) and preoperative dialyses (OR: 3.499, p = 0.010) were predictive for long-term mortality in our Cox regression model, sex (p = 0.466) was not. There was no statistical difference in overall survival (log rank: p = 0.425). CONCLUSIONS Female patients are older but reveal fewer cardiovascular risk factors; aneurysms are more common in female than male patients. As female patients undergo concomitant surgical procedures less often, their operative times are shorter. While survival and outcomes were similar, female patients suffered from postoperative new in-stent thrombus formation significantly more often.
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Affiliation(s)
- Julia Benk
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Matthias D'Inka
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Magdalena Bork
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Tim Walter
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Philipp Discher
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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5
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Crousillat D, Briller J, Aggarwal N, Cho L, Coutinho T, Harrington C, Isselbacher E, Lindley K, Ouzounian M, Preventza O, Sharma J, Sweis R, Russo M, Scott N, Narula N. Sex Differences in Thoracic Aortic Disease and Dissection: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 82:817-827. [PMID: 37612014 DOI: 10.1016/j.jacc.2023.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/05/2023] [Accepted: 05/17/2023] [Indexed: 08/25/2023]
Abstract
Despite its higher prevalence among men, women with thoracic aortic aneurysm and dissection (TAAD) have lower rates of treatment and surgical intervention and often have worse outcomes. A growing number of women with TAAD also desire pregnancy, which can be associated with an increased risk of aortic complications. Understanding sex-specific differences in TAAD has the potential to improve care delivery, reduce disparities in treatment, and optimize outcomes for women with TAAD.
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Affiliation(s)
- Daniela Crousillat
- Division of Cardiovascular Sciences, Department of Medicine and Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
| | - Joan Briller
- Division of Cardiology, Department of Medicine, University Illinois at Chicago, Chicago, Illinois, USA
| | - Niti Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | - Leslie Cho
- Department of Cardiovascular Medicine, Heart, Vascular Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thais Coutinho
- Division of Cardiology, Division of Cardiac Prevention and Rehabilitation, Canadian Women's Heart Health Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Colleen Harrington
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Isselbacher
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathryn Lindley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Maral Ouzounian
- Peter Munk Cardiac Centre, Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ourania Preventza
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA; Cardiothoracic Surgery, University of Virginia Health, Charlottesville, Virginia, USA
| | - Jyoti Sharma
- Piedmont Heart Institute, Department of Cardiology, Atlanta, Georgia, USA
| | - Ranya Sweis
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Melissa Russo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Women & Infants Hospital, Providence, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nandita Scott
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nupoor Narula
- Division of Cardiology and Weill Cornell Women's Heart Program, Weill Cornell Medicine, New York, New York, USA
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6
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 424] [Impact Index Per Article: 212.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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7
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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8
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Edman NI, Zettervall SL, Dematteis MN, Ghaffarian A, Shalhub S, Sweet MP. Women with Thoracoabdominal Aortic Aneurysms Have Increased Frailty and More Complex Aortic Anatomy Compared with Men. J Vasc Surg 2022; 76:61-69.e3. [DOI: 10.1016/j.jvs.2022.01.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
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9
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Voigt KR, Gökalp AL, Papageorgiou G, Bogers AJ, Takkenberg JJ, Mokhles MM, Bekkers JA. Male-Female Differences In Ascending Aortic Aneurysm Surgery: 25-Year Single Center Results. Semin Thorac Cardiovasc Surg 2022; 35:300-308. [DOI: 10.1053/j.semtcvs.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 01/15/2023]
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10
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Cho L, Kibbe MR, Bakaeen F, Aggarwal NR, Davis MB, Karmalou T, Lawton JS, Ouzounian M, Preventza O, Russo AM, Shroyer ALW, Zwischenberger BA, Lindley KJ. Cardiac Surgery in Women in the Current Era: What Are the Gaps in Care? Circulation 2021; 144:1172-1185. [PMID: 34606298 DOI: 10.1161/circulationaha.121.056025] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Cardiovascular disease remains the leading cause of morbidity and mortality for women in United States and worldwide. One in 3 women dies from cardiovascular disease, and 45% of women >20 years old have some form of CVD. Historically, women have had higher morbidity and mortality after cardiac surgery. Sex influences pathogenesis, pathophysiology, presentation, postoperative complications, surgical outcomes, and survival. This review summarizes current cardiovascular surgery outcomes as they pertain to women. Specifically, this article seeks to address whether sex disparities in research, surgical referral, and outcomes still exist and to provide strategies to close these gaps. In addition, with the growing population of women of reproductive age with cardiovascular disease and cardiovascular risk factors, indications for cardiac surgery arise in pregnant women. The current review will also address the unique issues associated with this special population.
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Affiliation(s)
- Leslie Cho
- Cleveland Clinic Heart and Vascular Institute, Ohio (L.C., F.B.,T.K.)
| | - Melina R Kibbe
- University of North Caroline Medical School, Chapel Hill (M.R.K.)
| | - Faisal Bakaeen
- Cleveland Clinic Heart and Vascular Institute, Ohio (L.C., F.B.,T.K.)
| | | | | | - Tara Karmalou
- Cleveland Clinic Heart and Vascular Institute, Ohio (L.C., F.B.,T.K.)
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11
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Sex, Racial, and Ethnic Disparities in U.S. Cardiovascular Trials in More Than 230,000 Patients. Ann Thorac Surg 2021; 112:726-735. [DOI: 10.1016/j.athoracsur.2020.08.075] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 08/07/2020] [Accepted: 08/31/2020] [Indexed: 11/23/2022]
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12
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Chan SM, Weininger G, Langford J, Jane-Wit D, Dardik A. Sex Differences in Inflammation During Venous Remodeling of Arteriovenous Fistulae. Front Cardiovasc Med 2021; 8:715114. [PMID: 34368264 PMCID: PMC8335484 DOI: 10.3389/fcvm.2021.715114] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/24/2021] [Indexed: 12/18/2022] Open
Abstract
Vascular disorders frequently have differing clinical presentations among women and men. Sex differences exist in vascular access for hemodialysis; women have reduced rates of arteriovenous fistula (AVF) maturation as well as fistula utilization compared with men. Inflammation is increasingly implicated in both clinical studies and animal models as a potent mechanism driving AVF maturation, especially in vessel dilation and wall thickening, that allows venous remodeling to the fistula environment to support hemodialysis. Sex differences have long been recognized in arterial remodeling and diseases, with men having increased cardiovascular events compared with pre-menopausal women. Many of these arterial diseases are driven by inflammation that is similar to the inflammation during AVF maturation. Improved understanding of sex differences in inflammation during vascular remodeling may suggest sex-specific vascular therapies to improve AVF success.
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Affiliation(s)
- Shin Mei Chan
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, United States
| | - Gabe Weininger
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, United States
| | - John Langford
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, United States.,Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Daniel Jane-Wit
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, United States.,Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,Department of Immunobiology, Yale School of Medicine, New Haven, CT, United States
| | - Alan Dardik
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, United States.,Department of Surgery, Yale School of Medicine, New Haven, CT, United States.,Department of Surgery, Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, United States
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13
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Chatterjee S, Shi A, Yoon L, Green SY, Zhang Q, Amarasekara HS, Orozco-Sevilla V, Preventza O, LeMaire SA, Coselli JS. Effect of sarcopenia on survival and spinal cord deficit outcomes after thoracoabdominal aortic aneurysm repair in patients 60 years of age and older. J Thorac Cardiovasc Surg 2021; 165:1985-1996.e3. [PMID: 34147254 DOI: 10.1016/j.jtcvs.2021.05.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 04/14/2021] [Accepted: 05/19/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Sarcopenia (core muscle loss) has been used as a surrogate marker of frailty. We investigated whether sarcopenia would adversely affect survival after thoracoabdominal aortic aneurysm repair. METHODS We retrospectively reviewed prospectively collected data from patients aged 60 years or older who underwent thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Imaging was reviewed by 2 radiologists blinded to clinical outcomes. The total psoas index was derived from total psoas muscle cross-sectional area (cm2) at the mid-L4 level, normalized for height (m2). Patients were divided by sex-specific total psoas index values into sarcopenia (lower third) and nonsarcopenia (upper two-thirds) groups. Multivariable modeling identified operative mortality and spinal cord injury predictors. Unadjusted and adjusted survival curves were analyzed. RESULTS Of 392 patients identified, those with sarcopenia (n = 131) were older than nonsarcopenic patients (n = 261) (70.0 years vs 68.0 years; P = .02) and more frequently presented with aortic rupture or required urgent/emergency operations. Operative mortality was comparable (sarcopenia 13.7% vs nonsarcopenia 10.0%; P = .3); sarcopenia was not associated with operative mortality in the multivariable model (odds ratio, 1.40; 95% confidence interval, 0.73-2.77; P = .3). Sarcopenic patients experienced more frequent delayed (13.0% vs 4.6%; P = .005) and persistent (10.7% vs 3.4%; P = .008) paraplegia. Sarcopenia independently predicted delayed paraplegia (odds ratio, 3.17; 95% confidence interval, 1.42-7.08; P = .005) and persistent paraplegia (odds ratio, 3.29; 95% confidence interval, 1.33-8.13; P = .01) in the multivariable model. Adjusted for preoperative/operative covariates, midterm survival was similar for sarcopenic and nonsarcopenic patients (P = .3). CONCLUSIONS Sarcopenia did not influence early mortality or midterm survival after thoracoabdominal aortic aneurysm repair but was associated with greater risk for delayed and persistent paraplegia.
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Affiliation(s)
- Subhasis Chatterjee
- Division of General Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
| | - Ann Shi
- CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Department of Radiology, Baylor College Medicine, Houston, Tex
| | - Luke Yoon
- Department of Radiology, Baylor College Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Qianzi Zhang
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
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Preventza O, Cekmecelioglu D, Chatterjee S, Green SY, Amarasekara H, Zhang Q, LeMaire SA, Coselli JS. Sex Differences in Ascending Aortic and Arch Surgery: A Propensity-matched Comparison of 1153 Pairs. Ann Thorac Surg 2021; 113:1153-1158. [PMID: 33971171 DOI: 10.1016/j.athoracsur.2021.04.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND We investigated the relationship of sex with clinical outcomes after proximal aortic (ascending and arch) operations, and whether sex-specific preoperative factors are associated with mortality. METHODS Of 3745 patients who underwent elective, urgent, and emergency proximal aortic operations over a 20-year period, 1153 pairs of men and women were propensity-matched, and their early and long-term outcomes were compared. Kaplan-Meier survival analysis was used to estimate late survival. RESULTS Women and men had similar operative mortality (9.1% vs 8.8%, P=0.8), stroke (5.7% vs 5.6%, P=0.9), and renal failure rates (7.0% vs 6.6%, P=0.7). Thirty-day mortality was 7.5% versus 5.6% (P=0.06), respectively. Results were less favorable for women than for men regarding respiratory failure (34.3% vs 29.2%, P=0.008) and intensive care unit length of stay (9.11±11.9 vs 7.87±12.48 days; P=0.023). Long-term survival was not significantly different between women and men: 66.3% (95%CI 62.8-69.5) versus 67.1% (95%CI 63.6-70.4) at 5 years, and 45.9% (95%CI 41.76-50.0) versus 46.2% (95%CI 41.7-50.6) at 10 years (P=0.4). Preoperative factors including diabetes, prior stroke, prior renal insufficiency, and peripheral vascular disease were associated with operative mortality in men, whereas chronic obstructive pulmonary disease was the main risk factor in women. CONCLUSIONS No differences were seen between the sexes in life-changing adverse outcomes after ascending aortic and arch procedures, although specific preoperative variables were associated with specific adverse events. Recognizing differences in preoperative risk factors for mortality between the sexes may facilitate targeted preoperative assessment, preparation, and counseling.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center.
| | - Davut Cekmecelioglu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
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15
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Edman NI, Schanzer A, Crawford A, Oderich GS, Farber MA, Schneider DB, Timaran CH, Beck AW, Eagleton M, Sweet MP. Sex-related outcomes after fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms in the U.S. Fenestrated and Branched Aortic Research Consortium. J Vasc Surg 2021; 74:861-870. [PMID: 33775747 DOI: 10.1016/j.jvs.2021.02.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/28/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Fenestrated-branched endovascular aneurysm repair (FBEVAR) has expanded the treatment of patients with thoracoabdominal aortic aneurysms (TAAAs). Previous studies have demonstrated that women are less likely to be treated with standard infrarenal endovascular aneurysm repair because of anatomic ineligibility and experience greater mortality after both infrarenal and thoracic aortic aneurysm repair. The purpose of the present study was to describe the sex-related outcomes after FBEVAR for treatment of TAAAs. METHODS The data from 886 patients with extent I to IV TAAAs (excluding pararenal or juxtarenal aneurysms), enrolled in eight prospective, physician-sponsored, investigational device exemption studies from 2013 to 2019, were analyzed. All data were collected prospectively, audited and adjudicated by clinical events committees and/or data safety monitoring boards, and subject to Food and Drug Administration oversight. All the patients had been treated with Cook-manufactured patient-specific FBEVAR devices or the Cook t-Branch off-the-shelf device (Cook Medical, Brisbane, Australia). RESULTS Of the 886 patients who underwent FBEVAR, 288 (33%) were women. The women had more extensive aneurysms and a greater prevalence of diabetes (33% vs 26%; P = .043) but a lower prevalence of coronary artery disease (33% vs 52%; P < .0001) and previous infrarenal endovascular aneurysm repair (7.6% vs 16%; P < .001). The women had required a longer operative time from incision to surgery end (5.0 ± 1.8 hours vs 4.6 ± 1.7 hours; P < .001), experienced lower technical success (93% vs 98%; P = .002), and were less likely to be discharged to home (72% vs 83%; P = .009). Despite the smaller access vessels, the women did not have an increased incidence of access site complications. Also, the 30-day outcomes were broadly similar between the sexes. At 1 year, no differences were found between the women and men in freedom from type I or III endoleak (91.4% vs 92.0%; P = .64), freedom from reintervention (81.7% vs 85.3%; P = .10), target vessel instability (87.5% vs 89.2%; P = .31), and survival (89.6% vs 91.7%; P = .26). The women had a greater incidence of postoperative sac expansion (12% vs 6.5%; P = .006). Multivariable modeling adjusted for age, aneurysm extent, aneurysm size, urgent procedure, and renal function showed that patient sex was not an independent predictor of survival (hazard ratio, 0.83; 95% confidence interval, 0.50-1.37; P = .46). CONCLUSIONS Women undergoing FBEVAR demonstrated metrics of increased complexity and had a lower level of technical success, especially those with extensive aneurysms. Compared with the men, the women had similar 30-day mortality and 1-year outcomes, with the exception of an increased incidence of sac expansion. These data have demonstrated that FBEVAR is safe and effective for women and men but that further efforts to improve outcome parity are indicated.
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Affiliation(s)
- Natasha I Edman
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash; Medical Scientist Training Program, University of Washington, Seattle, Wash
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts, Worcester, Mass
| | - Allison Crawford
- Division of Vascular Surgery, University of Massachusetts, Worcester, Mass
| | - Gustavo S Oderich
- Advanced Endovascular Aortic Program, Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Carlos H Timaran
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, Tex
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash.
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16
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Preventza O, Backhus L. US women in thoracic surgery: reflections on the past and opportunities for the future. J Thorac Dis 2021; 13:473-479. [PMID: 33569234 PMCID: PMC7867830 DOI: 10.21037/jtd.2020.04.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Herein, we examine the state of women in thoracic surgery from the United States (US) perspective in terms of our past, present, and opportunities for the future. We explore the achievements of the first three women certified in thoracic surgery in 1961 and describe the progress made resulting in the current state. Women constitute slightly more than 50% of all medical students in the US, yet women remain underrepresented in thoracic surgery. The disparity is most notable for female representation in senior academic leadership positions, reflecting stagnation in progress. The lack of gender equity has important implications for projected workforce shortages and patient safety in cardiothoracic surgery. Recent organized efforts in scholarships and leadership training, as well as increasing awareness and mentorship, may herald progress on the horizon. Ultimately, however, engagement of leadership and top-down change are needed to achieve equity and, thereby, to improve patient health and satisfaction.
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Affiliation(s)
- Ourania Preventza
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Leah Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
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17
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Chung J, Coutinho T, Chu MWA, Ouzounian M. Sex differences in thoracic aortic disease: A review of the literature and a call to action. J Thorac Cardiovasc Surg 2020; 160:656-660. [PMID: 31987620 DOI: 10.1016/j.jtcvs.2019.09.194] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/08/2019] [Accepted: 09/11/2019] [Indexed: 01/15/2023]
Affiliation(s)
- Jennifer Chung
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada
| | - Thais Coutinho
- Division of Cardiology, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada.
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Latz CA, Boitano L, Wang LJ, Chou E, DeCarlo C, Pendleton AA, Mohebali J, Conrad M. Female Sex Portends Worse Long-Term Survival after Open Type I-III Thoracoabdominal Aneurysm Repair. Ann Vasc Surg 2020; 70:162-170. [PMID: 32738386 DOI: 10.1016/j.avsg.2020.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 07/18/2020] [Accepted: 07/19/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although outcomes after infrarenal abdominal aortic aneurysm surgery are worse in females, sex-specific differences in outcomes after open thoracoabdominal aortic aneurysm (TAAA) repair are less clear. The goal of this study was to identify sex-based disparities in short- and long-term outcomes after open type I-III TAAA surgery. METHODS All open type I-III TAAA repairs performed from 1987 to 2015 were evaluated using an institutional database. Charts were retrospectively evaluated for perioperative outcomes: major adverse events (MAEs), in-hospital death, and long-term survival. Univariate analysis was performed using the Fisher's exact test for categorical variables and the Wilcoxon rank-sum test for continuous variables. Logistic regression was used for in-hospital end points; survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. Sensitivity analyses were performed for relevant multivariable models, one with ruptures removed and another evaluating only repairs performed before 2006 to account for any selection bias due to wider use of complex endovascular technology. RESULTS Five-hundred sixteen patients underwent open type I-III TAAA repair during the study period. Females accounted for 54.3% (n = 280) of the cohort. Women were older, less likely to have a chronic dissection etiology, more likely to present with a symptomatic/ruptured lesion, and had a lower admission creatinine than men. Perioperative death occurred in 23 men (9.8%) and 19 women (6.8%) (P = 0.26); 133 women (47.3%) and 116 men (49.2%) suffered an MAE (P = 0.72). Multivariable analyses revealed no sex-based difference in perioperative death (Female sex adjusted odds ratio (AOR): 0.72, 95% confidence interval (CI): 0.4-1.4, P = 0.34) or MAE (AOR: 1.0 CI: 0.7-1.5, P = 0.82). Unadjusted survival at five years was 50% for women and 67% for men (log-rank P < 0.001). Female sex was an independent predictor of decreased survival (hazard ratio (HR): 1.5 95% CI: 1.2-1.9, P = 0.001) when adjusted for age, aneurysm extent, creatinine, chronic obstructive pulmonary disease, and ruptures. After removing all ruptures, female sex remained nonpredictive of perioperative death (AOR: 1.1, 95% CI 0.5-2.5, P = 0.75) or MAE (AOR: 1.2, CI: 0.8-1.9, P = 0.31) and predictive of decreased long-term survival (HR: 1.5, 95% CI: 1.2-2.0, P = 0.001). CONCLUSIONS Those undergoing open type I-III TAAA repair have similar rates of perioperative mortality and MAEs, regardless of sex. However, female sex is an independent risk factor for decreased long-term survival.
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Affiliation(s)
- Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Elizabeth Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Anna A Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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Sex-related outcomes after open type IV thoracoabdominal aortic aneurysm repair. J Vasc Surg 2020; 73:443-450. [PMID: 32623104 DOI: 10.1016/j.jvs.2020.05.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 05/22/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Although outcomes after infrarenal abdominal aortic aneurysm surgery are worse in women, sex-specific differences in outcomes after open type IV thoracoabdominal aortic aneurysm (TAAA) surgery are undefined. The goal of this study was to define sex-based disparities in short- and long-term outcomes after open type IV TAAA surgery. METHODS All open type IV TAAA repairs performed during 27 years were evaluated using a single institutional database. Charts were retrospectively evaluated for major adverse events (in-hospital death, other major in-hospital complication) and long-term complications (graft- and aortic-related events and death). Univariate analyses were performed using the Fisher's exact test for categorical variables and Wilcoxon rank-sum testing for continuous variables. Logistic multivariable regression was used for the in-hospital end points death and major complication, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. RESULTS During the 27-year study period, 234 patients had an open type IV TAAA repair; 85 were female and 149 were male. There were 26 (17.5%) men and 16 (18.8%) women who suffered a major in-hospital complication/death. There were eight (3.4%) in-hospital deaths, all occurring in men. Unadjusted survival at 5 years was 67.9% for women and 58.4% for men. Multivariable analyses revealed no sex-based difference in combined major in-hospital events and death (female: odds ratio [OR], 1.8; confidence interval [CI], 0.83-4.0; P = .13) or any complication (OR, 1.0; CI, 0.55-1.8; P = .99). However, women were less likely than men to be discharged to home (OR, 0.28; CI, 0.13-0.60; P = .001) and had decreased survival compared with men after discharge (hazard ratio, 2.1; CI, 1.2-3.5; P = .008). CONCLUSIONS No sex-based differences were found for the in-hospital outcomes of death or major complication after open type IV TAAA repair. However, women are less likely than men to be discharged home. Among those who survive the index operation, female sex portends decreased survival following discharge after repair.
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Nicolini F, Vezzani A, Corradi F, Gherli R, Benassi F, Manca T, Gherli T. Gender differences in outcomes after aortic aneurysm surgery should foster further research to improve screening and prevention programmes. Eur J Prev Cardiol 2019; 25:32-41. [PMID: 29708035 DOI: 10.1177/2047487318759121] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Gender-related biases in outcomes after thoracic aortic surgery are an important factor to consider in the prevention of potential complications related to aortic diseases and in the analysis of surgical results. Methods The aim of this study is to provide an up-to-date review of gender-related differences in the epidemiology, specific risk factors, outcome, and screening and prevention programmes in aortic aneurysms. Results Female patients affected by aortic disease still have worse outcomes and higher early and late mortality than men. It is difficult to plan new specific strategies to improve outcomes in women undergoing major aortic surgery, given that the true explanations for their poorer outcomes are as yet not clearly identified. Some authors recommend further investigation of hormonal or molecular explanations for the sex differences in aortic disease. Others stress the need for quality improvement projects to quantify the preoperative risk in high-risk populations using non-invasive tests such as cardiopulmonary exercise testing. Conclusions The treatment of patients classified as high risk could thus be optimised before surgery becomes necessary by means of numerous strategies, such as the administration of high-dose statin therapy, antiplatelet treatment, optimal control of hypertension, lifestyle improvement with smoking cessation, weight loss and careful control of diabetes. Future efforts are needed to understand better the gender differences in the diagnosis, management and outcome of aortic aneurysm disease, and for appropriate and modern management of female patients.
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Affiliation(s)
| | - Antonella Vezzani
- 2 General and Specialistic Surgery Department, Azienda Ospedaliero Universitaria di Parma, Italy
| | - Francesco Corradi
- 3 Anaesthesia and Intensive Care Unit, E.O. Ospedali Galliera, Italy
| | - Riccardo Gherli
- 4 Department of Cardiovascular Sciences, San Camillo Forlanini Hospital, Italy
| | - Filippo Benassi
- 2 General and Specialistic Surgery Department, Azienda Ospedaliero Universitaria di Parma, Italy
| | - Tullio Manca
- 2 General and Specialistic Surgery Department, Azienda Ospedaliero Universitaria di Parma, Italy
| | - Tiziano Gherli
- 1 Department of Medicine and Surgery, University of Parma, Italy
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Girardi LN, Leonard JR, Lau C, Ohmes LB, Gambardella I, Iannacone EM, Munjal M, Schwann AN, Gaudino MF. Gender-related outcomes after open repair of descending thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg 2019; 69:1028-1035.e1. [DOI: 10.1016/j.jvs.2018.06.213] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/13/2018] [Indexed: 11/17/2022]
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22
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Orozco-Sevilla V, Weldon SA, Coselli JS. Hybrid thoracoabdominal aortic aneurysm repair: is the future here? J Vis Surg 2018; 4:61. [PMID: 29682471 DOI: 10.21037/jovs.2018.02.14] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/08/2018] [Indexed: 11/06/2022]
Abstract
Open surgical repair has been the gold standard for thoracoabdominal aortic aneurysm (TAAA) repair for more than 6 decades, but 2 additional options have emerged: total endovascular TAAA repair and a hybrid approach that combines open and endovascular repair. Despite the optimism for an endovascular approach, long-term results for these repairs are still lacking. Some of the issues with this emerging technology include the risk of paraplegia after extensive endovascular repair, the need for multiple reinterventions, continuous stent-graft surveillance, endograft branch stenosis, as well as the significant learning curve. Interest in a hybrid approach has resurged despite the non-superior results compared to open TAAA. Commonly, the focus of the hybrid approach is now on performing a less extensive open TAAA repair, which is then extended with a stent-graft or vice versa. Moreover, this approach is now often performed in two stages in an effort to decrease the associated spinal cord ischemia. Open surgical repair after endovascular aortic repair is increasingly being performed to address serious complications, such as infection or fistula, that cannot be repaired by further endovascular intervention. As with any new technology, there will be an increase in the number of procedure-related complications and a decrease in the number of surgeons who can perform the traditional open operation with good results.
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Affiliation(s)
- Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Scott A Weldon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas, USA
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To find the least common denominator—or better—do not merely reduce to the max. J Thorac Cardiovasc Surg 2017. [DOI: 10.1016/j.jtcvs.2017.05.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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24
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Di Marco L, Murana G, Pacini D. Open thoracoabdominal aortic aneurysm repair: Is there a "sex problem"? J Thorac Cardiovasc Surg 2017; 154:1215-1216. [PMID: 28666668 DOI: 10.1016/j.jtcvs.2017.05.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Luca Di Marco
- Cardiac Surgery Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Cardiac Surgery Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Department, S. Orsola Hospital, University of Bologna, Bologna, Italy.
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