Gender trends in the repair of ruptured abdominal aortic aneurysms and outcomes

The Comparison of Endovascular and Open Surgical Treatment for Ruptured Abdominal Aortic Aneurysm in Terms of Safety and Efficacy on the Basis of a Single-Center 30-Year Experience

OBJECTIVE

Ruptured abdominal aortic aneurysm (rAAA) is a critical condition with a high mortality rate. Over the years, endovascular aortic repair (EVAR) has evolved as a viable treatment option in addition to open repair (OR). The primary objective of this study was to compare the safety and efficacy of EVAR and OR for the treatment of rAAA based on a comprehensive analysis of our single-centre 30-year experience.

METHODS

Patients treated for rAAA at the Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Germany from 1 January 1993 to 31 December 2022 were included. Relevant information was retrieved from archived medical records. Patient survival and surgery-related complications were analysed.

RESULTS

None of the patient-specific markers, emergency department-associated parameters, and co-morbidities were associated with patient survival. The 30-day and in-hospital mortality was higher in the OR group vs. in the EVAR group (50% vs. 8.7% and 57.1% vs. 13%, respectively). OR was associated with more frequent occurrence of more severe complications when compared to EVAR. Overall patient survival was 56 ± 5% at 12 months post-surgery (52 ± 6% for OR vs. 73 ± 11% for EVAR, respectively) (p < 0.05). Patients ≥70 years of age showed poorer survival in the OR group, with a 12-month survival of 42 ± 7% vs. 70 ± 10% for patients <70 years of age (p < 0.05). In the EVAR group, this age-related survival advantage was not found (12-month survival: ≥70 years: 67 ± 14%, <70 years: 86 ± 13%). Gender-specific survival was similar regardless of the applied method of care.

CONCLUSION

OR was associated with more severe complications in our study. EVAR initially outperformed OR for rAAA regarding patient survival while re-interventions following EVAR negatively affect survival in the long-term. Elderly patients should be treated with EVAR. Gender does not seem to have a significant impact on survival.

A Systematic Review of the Recruitment and Outcome Reporting by Sex and Race/Ethnicity in Stent Device Development Trials for Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

Women and racial/ethnic minority groups have been shown to experience poor outcomes after endovascular aortic aneurysm repair (EVAR). One potential reason is the rare inclusion of these populations in initial phases of device development. The objective of this systematic review is to understand enrollment and outcome reporting by sex and race/ethnicity in industry-funded EVAR device development trials.

METHODS

MEDLINE, PubMed, and Embase were searched from inception to January 2022 without language restrictions using the following terminology: "stent", "graft", "endograft", "device", and "abdominal aortic aneurysm" (AAA).

CLINICALTRIALS

gov was also searched from inception to January 2022 for "AAA." Two independent reviewers screened and extracted data. All phase I-III and postmarket evaluation trials that included patients ≥18 years of age, who underwent EVAR were assessed. Participation-to-prevalence ratios (PPRs) were calculated to estimate representation of participants by sex and race/ethnicity in trials compared with their share of disease burden.

RESULTS

Among the 4,780 retrieved articles, 55 industry-funded trials met inclusion criteria for this review. A total of 51 trials (93%) reported enrollment by sex/gender, and only 7 trials (13%) reported enrollment by race/ethnicity of the participants. A median of 19 (interquartile range [IQR]: 4.5, 51) women participants were recruited compared to 171 (IQR: 57, 311.5) men, and 17 (IQR: 7.5, 21.5) racial/minority patients were recruited compared to 241 (IQR: 123, 463.5) White participants. Women represent 16.6% of the disease population, and the median PPR is 0.62 (IQR: 0.42, 0.88), which has remained constant over time (Figure 1). None of the device trials reported outcomes based on sex/gender or race/ethnicity.

CONCLUSIONS

This systematic review highlights the disparities in recruitment and outcome reporting based on sex and race/ethnicity in EVAR device development trials. While most trials may be underpowered to study these differences, recent registry studies show differential outcomes based on sex and race/ethnicity of vascular patients. Therefore, it is imperative to include and report outcomes in these participants, starting from the initial device development phases to improve generalizability of device-use and understand sources of variation in device performance.

Association of Premature Menopause With Risk of Abdominal Aortic Aneurysm in the Women's Health Initiative

OBJECTIVE

To determine if premature menopause and early menarche are associated with increased risk of AAA, and to explore potential effect modification by smoking history.

SUMMARY OF BACKGROUND DATA

Despite worse outcomes for women with AAA, no studies have prospectively examined sex-specific risk factors, such as premature menopause and early menarche, with risk of AAA in a large, ethnically diverse cohort of women.

METHODS

This was a post-hoc analysis of Women's Health Initiative participants who were beneficiaries of Medicare Parts A&B fee-for-service. AAA cases and interventions were identified from claims data. Follow-up period included Medicare coverage until death, end of follow-up or end of coverage inclusive of 2017.

RESULTS

Of 101,119 participants included in the analysis, the mean age was 63 years and median follow-up was 11.3 years. Just under 10,000 (9.4%) women experienced premature menopause and 22,240 (22%) experienced early men-arche. Women with premature menopause were more likely to be overweight, Black, have >20 pack years of smoking, history of cardiovascular disease, hypertension, and early menarche. During 1,091,840 person-years of follow-up, 1125 women were diagnosed with AAA, 134 had premature menopause (11.9%), 93 underwent surgical intervention and 45 (48%) required intervention for ruptured AAA. Premature menopause was associated with increased risk of AAA [hazard ratio 1.37 (1.14, 1.66)], but the association was no longer significant after multivariable adjustment for demographics and cardiovascular disease risk factors. Amongst women with ≥20 pack year smoking history (n = 19,286), 2148 (11.1%) had premature menopause, which was associated with greater risk of AAA in all models [hazard ratio 1.63 (1.24, 2.23)]. Early menarche was not associated with increased risk of AAA.

CONCLUSIONS

This study finds that premature menopause may be an important risk factor for AAA in women with significant smoking history. There was no significant association between premature menopause and risk of AAA amongst women who have never smoked. These results suggest an opportunity to develop strategies for better screening, risk reduction and stratification, and outcome improvement in the comprehensive vascular care of women.

Sex Influence on Fenestrated and Branched Endovascular Aortic Aneurysm Repair: Outcomes From a National Multicenter Registry

Introduction:

Women are generally underrepresented in trials focusing on aortic aneurysm. Nevertheless, sex-related differences have recently emerged from several studies and registries. The aim of this research was to assess whether sex-related anatomical disparities existed in fenestrated and branched aortic repair candidates and whether these discrepancies could influence endovascular repair outcomes.

Methods:

Data from all consecutive patients treated during the 2008–2019 period within the Italian Multicenter fenestrated or branched endovascular aortic repair (F/BEVAR) Registry were included in the present study. Propensity matching was performed using a logistic regression model adjusted for demographic data and comorbidities to obtain comparable male and female samples. The selection model led to a final study population of 176 patients (88 women and 88 men) among the total initial cohort of 596. Study endpoints were technical and clinical success, overall survival, aneurysm-related death, and reintervention rates evaluated at 30 days and during follow-up.

Results:

Twenty-eight patients (15.9%) received urgent/emergent repair. In most of the cases (71.6%), women received treatment for extensive thoracoabdominal pathology (Crawford type I, II, or III aneurysm rather than type IV or juxta-pararenal) versus 46.6% of men (p=0.001). Female patients presented with more challenging iliac accesses with at least one side considered hostile in 27.3% of the cases (vs 13.6% in male patients, p=0.039). Finally, women had significantly smaller visceral vessels. Women had significantly worse operative outcomes, with an 86.2% technical success rate versus 96.6% in the male population (p=0.016). No differences were recorded in terms of 30-day reinterventions between men and women. The 5-year estimate of freedom from late reintervention, according to Kaplan-Meier analysis, was 85.6% in men versus 81.6% in women (p=ns). No aneurysm-related death was recorded during follow-up (median observational time, 23 months [interquartile range, 7–45 months]).

Conclusion:

Women presented a significantly higher incidence of thoracoabdominal aneurysms, smaller visceral vessels, and more complex iliofemoral accesses, resulting in a significantly lower technical success after F/BEVAR. Further studies assessing sex-related differences are needed to properly determine the impact on outcomes and stratify procedural risks.

Clinical Impact

Women are generally underrepresented in trials focusing on aortic aneurysms. Aiming to assess whether sex may affect outcomes after a complex endovascular aortic repair, a propensity score selection was applied to a total population of 596 patients receiving F/BEVAR aortic repair with the Cook platform, matching each treated female patient with a corresponding male patient. Women presented more frequently a thoracoabdominal aneurysm extent, smaller visceral vessels, and complex iliofemoral accesses, resulting in significantly worse operative outcomes, with an 86.2% technical success versus 96.6% (p=0.016). No differences were recorded in terms of short-term and mid-term reinterventions. According to these results, careful and critical assessment should be posed in case of female patients receiving complex aortic repair, especially regarding preoperative anatomical evaluation and clinical selection with appropriate surgical risk stratification.

Female Sex Is Associated With Reintervention and Mortality Following Elective Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVE

While sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes are increasingly reported, but contributing factors remain without consensus. We investigated disparities in sex-specific outcomes following elective EVAR at our institution and evaluated factors that may predispose females to increased morbidity and mortality.

METHODS

A retrospective chart review of all patients undergoing elective EVAR from 2011 to 2020 at a suburban tertiary care center was performed. The primary outcomes were five-year survival and freedom from reintervention. Fisher's exact test, t-tests, and Kaplan-Meier analysis using the rank-log test investigated associations between sex and outcomes. A multivariable Cox proportional hazard model controlling for age and common comorbidities evaluated the effect of sex on survival and freedom from reintervention.

RESULTS

Two hundred and seventy-three patients underwent elective EVAR during the study period, including 68 (25%) females and 205 (75%) males. Females were older on average than males (76 years vs. 73 years, p= <0.01) and were more likely to have chronic obstructive pulmonary disease (COPD; 38% versus 23%, p=0.01), require home oxygen therapy (9% versus 2%, p=0.04) or dialysis preoperatively (4% versus 0%, p=0.02). Distribution of other common vascular comorbidities was similar between the sexes. Thirty-day readmission was greater in females than males (18% versus 8%, p=0.02). Females had significantly lower survival at five years (48% ± 7.9% versus 65% ± 4.3%, p<0.01) and significantly lower one-year (89% ± 4.1% for females vs. 94% ± 1.7% for males, p=0.01) and five-year freedom from reintervention (69% ± 8.9% versus 84% ± 3.3%, p=0.02). On multivariable analysis, female sex (hazard ratio [HR]: 1.8, 95% confidence interval [CI]: 1.1-2.9), congestive heart failure (HR: 2.2, 95% CI: 1.2-3.9) and age (HR: 1.1, 95% CI: 1.0-1.1) were associated with 5-year mortality. Female sex remained as the only variable with a statistically significant association with five-year reintervention (HR: 2.4, 95% CI: 1.1-4.9).

CONCLUSIONS

Female sex was associated with decreased five-year survival and increased one and five-year reintervention following elective EVAR. Data from our institution suggests factors beyond patient age and baseline health risk likely contribute to greater surgical morbidity and mortality for females following elective EVAR.

Optimal timing of surveillance ultrasounds in small aortic aneurysms

OBJECTIVE

Small abdominal aortic aneurysms (AAA) surveillance intervals remain controversial and difficult to standardize. Current Society for Vascular Surgery guidelines lack quality evidence. The objective of this study is to examine patients followed in a high volume non-invasive vascular laboratory, determine if the current guidelines are fitting in clinical practice, and attempt to further identify risk factors for accelerated aneurysm growth.

METHODS

A retrospective analysis of patients who underwent at least two ultrasounds for AAA in the vascular laboratory during 2008-2018 with baseline diameter less than 5.0 cm was conducted. Patient demographics were collected. Groups were then created for comparison using the size criteria according to SVS guidelines. In addition, we compared overall growth rates specifically evaluating rapid growth (rate of at least 1.0 cm/year and size change of at least 0.5 cm from previous imaging), expected growth (any growth below 1.0 cm/year and of at least 0.5 cm from baseline) and no growth.

RESULTS

A total of 1581 patients (1232 male and 349 female) were identified with a total of 5945 ultrasound studies. The median age was 73 years and mean follow-up was 27.8 months. Baseline AAA size was 3.0-3.9 cm in 986 patients and 4.0-4.9 cm in 595 patients. The average maximum growth rate was 0.18 cm/year for AAAs 3.0-3.9 cm and 0.36 cm/year for AAAs 4.0-4.9 cm (p<0.001). Patients with AAA 4.0-4.9 cm at baseline were more likely to be white, male, hypertensive and have chronic kidney disease (p <0.05). 1078 patients (68.2%) demonstrated no growth over the observed time period with 342 patients (21.6%) demonstrating expected growth and 161 (10.2%) rapid growth. Male gender and baseline AAA size of 4.0-4.9 cm were more likely to demonstrate rapid growth (p=0.002) and eventual repair (p<0.001). Metformin use was more common in the AAA group with no growth (p <0.05). Freedom from rapid growth and repair indication at two years was significantly lower in those patients with baseline aneurysms 3.0-3.9 cm (p<0.001).

CONCLUSIONS

The overall low rate of events in small AAAs supports continued surveillance every 3 years for AAAs between 3.0 and 3.9 cm and yearly for male patients with AAAs 4.0-4.9 cm as recommended by the SVS Guidelines. Female gender may have less rapid growth than previously reported but likely merit more rigorous surveillance particularly as the AAAs approach 5.0 cm. Metformin use continues to demonstrate it may abrogate aneurysmal growth. Lastly, there is a subset of patients that exhibit more rapid growth of their small AAAs, and further study will be required to further classify these patients.

Patients on AAA surveillance are at greater threat of cardiovascular events or malignancy than their AAA: Outcomes of AAA surveillance over 19 years at a tertiary vascular centre

OBJECTIVE

To analyse 19 years' worth of data from a Major UK Vascular Centre to determine the outcome of patients after they enter AAA surveillance (surgery, death, discharge or transfer), this may inform interventions to improve these outcomes in the AAA surveillance population.

METHODS

This was a retrospective analysis of a prospectively collected database of outcomes of every patient entered on AAA surveillance at Manchester University NHS Foundation Trust - Wythenshawe Hospital between September 2000 and June 2019. Analyses included what proportion suffered death, discharge, transfer or surgery whilst on surveillance. Multi-variate analysis was used to determine the effect of initial AAA size, age when entering surveillance and gender. Boxplots were produced in those who had already reached an outcome to determine historic median times. Causes of death/discharge were also analysed.

RESULTS

1951 patients were identified from the databased after data cleaning and were included in the final analysis. 32.0% of patients had died, 23.8% had surgery, 13.3% were discharged due to worsening/severe comorbidity, 3.1% had been transferred and 27.7% were still active in surveillance. A longer time to surgery was significantly associated with increasing age on entering surveillance OR (95% CI) 0.95 (0.94 - 0.96) (p<0.001), smaller initial AAA size 4.26 (3.80 - 4.78) (p<0.001) but not female gender. Impaired survival was associated with increasing age 1.06 (1.05 - 1.07) (p<0.001), initial AAA size, 1.56 (1.39 - 1.74) (p<0.001) and female gender 1.40 (1.18 - 1.67) (p<0.001). Overall, death occurred more frequently than operative repair every year over all 15 years. Out of the deaths where cause was known (n=401), 34.9% (n=108) were due to cardiovascular events, 27.3% (n=109) due to malignancy (primarily lung), and 19.3% due to respiratory disease.

CONCLUSIONS

Based on this data, death, primarily due to cardiovascular events, is a more likely outcome than operative repair in patients on AAA surveillance and is associated with increasing age, increasing AAA size and female gender. A median time on surveillance of over three and a half years provides sufficient time to affect subsequent health outcomes in this population and therefore a shift of focus of AAA surveillance programmes to address cardiovascular, malignancy and respiratory disease risk is warranted.

Clinical Features of Tuberculosis Pseudoaneurysm and Risk Factors for Mortality

OBJECTIVES

The objective of this study was to determine the clinical features of tuberculosis aneurysms and risk factors for mortality.

MATERIALS AND METHOD

We reviewed all case reports of tuberculous aneurysms in the English literature from January 2000 to December 2020. The clinical features and possible risk factors for mortality were recorded and analyzed.

RESULT

In total, 174 cases of tuberculosis aneurysms were identified. The morbidity of men was more than twice that of women. Male patients (51.47±20.67 years) were older than female patients (39.52±20.23 years), p<0.05. The rupture rate of women (69.2%) was higher than that of men (48.8%). TB-induced aneurysms often spontaneously ruptured 1.41-3.01 months after the onset of TB symptoms without any treatment, and Bacillus Calmette-Guerin (BCG)-induced aneurysms often spontaneously ruptured 10.51-26.49 months after BCG administration. The morbidity of large artery aneurysms was nearly twice that of middle artery aneurysms. However, middle artery aneurysms were more likely to rupture (75.4%) than large artery aneurysms (43.5%), p<0.05. The rupture rate of BCG-induced aneurysms (37.0%) was lower than that of TB-induced aneurysms, regardless of whether there was a TB history (56.7%) or not (57.7%). Symptoms of TB occurred in 63.2% of patients, but only 8.6% of patients had both symptoms of TB and aneurysmal mass effects. Pain was the most common atypical clinical manifestation (50.0%). The Cox proportional hazards regression analysis and Kaplan-Meier estimator showed that rupture and no combined therapy were risk factors for mortality.

CONCLUSION

Tuberculosis aneurysms seemingly shared the same demographic characteristics as common aneurysms. The clinical features of TB-induced aneurysms were different from those of BCG-induced aneurysms in terms of the aneurysm loactation and rupture rate. Tuberculosis aneurysms may occur at any site of the cardiovascular system with a preponderance for large arteries. The changeable clinical manifestations were an important index for diagnosis, but focusing only on clinical manifestations may lead to a missed diagnosis. The combination of anti-TB medications and surgery before aneurysm rupture may provide the best prognosis.

Ultrasound screening for abdominal aortic aneurysm in high-risk women

Background

Population-wide ultrasound screening programmes for abdominal aortic aneurysm (AAA) for men have already been established in some countries. Women account for one third of aneurysm-related mortality and are four times more likely to experience an AAA rupture than men. Whole-population screening for AAA in women is unlikely to be clinically or economically effective. The aim of this study was to determine the outcomes of a targeted AAA screening programme for women at high risk of AAA.

Method

Women aged 65–74 years deemed at high risk of having an AAA (current smokers, ex-smokers, or with a history of coronary artery disease) were invited to attend ultrasound screening (July 2016 to March 2019) for AAA in the Female Aneurysm screening STudy (FAST). Primary outcomes were attendance for screening and prevalence of AAA. Biometric data, medical history, quality of life (QoL) and aortic diameter on ultrasound imaging were recorded prospectively.

Results

Some 6037 women were invited and 5200 attended screening (86.7 per cent). Fifteen AAAs larger than 29 mm were detected (prevalence 0.29 (95 per cent c.i. 0.18 to 0.48) per cent). Current smokers had the highest prevalence (0.83 (95 per cent c.i. 0.34 to 1.89) per cent) but lowest attendance (75.2 per cent). Three AAAs greater than 5.5 cm were identified and referred for consideration of surgical repair; one woman underwent repair. There was a significant reduction in patient-reported QoL scores following screening.

Conclusion

A low prevalence of AAA was detected in high-risk women, with lowest screening uptake in those at highest risk. Screening for AAA in high-risk women may not be beneficial.

A health insurance claims analysis on the effect of female sex on long-term outcomes after peripheral endovascular interventions for symptomatic peripheral arterial occlusive disease

OBJECTIVE

Several reports have addressed sex disparities in peripheral arterial occlusive disease (PAOD) treatment with inconclusive or even conflicting results. However, most previous studies have neither been sufficiently stratified nor used matching or weighting methods to address severe confounding. In the present study, we aimed to determine the disparities between sexes after percutaneous endovascular revascularization (ER) for symptomatic PAOD.

METHODS

Health insurance claims data from the second-largest insurance fund in Germany, BARMER, were used. A large cohort of patients who had undergone index percutaneous ER of symptomatic PAOD from January 1, 2010 to December 31, 2018 were included in the present study. The study cohort was stratified by the presence of intermittent claudication, ischemic rest pain, and wound healing disorders. Propensity score matching was used to adjust for confounding through differences in age, treated vessel region, comorbidities, and pharmacologic treatment. Sex-related differences regarding cardiovascular event-free survival, amputation-free survival, and overall survival within 5 years of surgery were determined using Kaplan-Meier time-to-event curves, log-rank test, and Cox regression analysis.

RESULTS

In the present study, 50,051 patients (47.2% women) were identified and used to compose a matched cohort of 35,232 patients. Among all strata, female patients exhibited lower mortality (hazard ratio [HR], 0.69-0.90), fewer amputations or death (HR, 0.70-0.89), and fewer cardiovascular events or death (HR, 0.78-0.91). The association between female sex and improved long-term outcomes was most pronounced for the patients with intermittent claudication.

CONCLUSIONS

In the present propensity score-matched analysis of health insurance claims, we observed superior cardiovascular event-free survival, amputation-free survival, and overall survival during 5 years of follow-up after percutaneous ER in women with symptomatic PAOD. Future studies should address sex disparities in the open surgical treatment of PAOD to illuminate whether the conflicting data from previous reports might have resulted from insufficient stratification of the studies.

Disparities in mortality after abdominal aortic aneurysm repair are linked to insurance status

OBJECTIVE

The objective of this study was to determine differences in mortality after abdominal aortic aneurysm (AAA) repair based on insurance type.

METHODS

In this retrospective cohort study, data from all-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California from January 2007 to December 2014 (excluding California, ending December 2011) were extracted from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. There were 90,102 patients ≥18 years old with available insurance data who underwent open AAA repair or endovascular aneurysm repair (EVAR) identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 3844, 3925, and 3971. EVAR patients were identified using the procedure code 3971, and the remainder of cases were categorized as open. Patients were divided into cohorts by insurance type as Medicare, Medicaid, uninsured (self-pay/no charge), other, or private insurance. Patients were further stratified for subgroup analyses by procedure type. Unadjusted rates of in-hospital mortality, the primary outcome, as well as secondary outcomes, such as surgical urgency, 30-day and 90-day readmissions, length of stay, total charges, and postoperative complications, were examined by insurance type. Adjusted odds ratios (ORs) for in-hospital mortality were calculated using multivariate logistic regression models fitted to the data. The multivariate models included patient-, surgical-, and hospital-specific factors with bivariate baseline testing suggestive of association with insurance status in addition to variables that were selected a priori.

RESULTS

Medicaid and uninsured patients had the highest rates of mortality relative to private insurance beneficiaries in all cohorts. Medicaid patients incurred a 47% increase in the odds of mortality, the highest among the insured, after all AAA repairs (OR, 1.47; 95% confidence interval [CI], 1.23-1.76), whereas uninsured patients experienced a 102% increase in the odds of mortality (OR, 2.02; 95% CI, 1.54-2.67). Subgroup analyses for open AAA repair and EVAR corroborated that Medicaid insurance (open repair OR, 1.37 [95% CI, 1.14-1.64]; EVAR OR, 2.06 [95% CI, 1.40-3.04]) and uninsured status (open repair OR, 1.85 [95% CI, 1.35-2.54]; EVAR OR, 2.96 [95% CI, 1.82-4.81]) were associated with the highest odds of mortality after both procedures separately.

CONCLUSIONS

This study demonstrates that Medicaid insurance and uninsured status are associated with higher unadjusted rates and adjusted ORs for in-hospital mortality after AAA repair relative to private insurance status. Primary payer status therefore serves as an independent predictor of the risk of death subsequent to AAA surgical interventions.

Perioperative, Postoperative, and Long-Term Outcomes Following Open Surgical Repair of Ruptured Abdominal Aortic Aneurysm

We investigated factors that affected perioperative, postoperative, and long-term outcomes of patients who underwent open emergency surgical repair of ruptured abdominal aortic aneurysms (RAAA). All patients who underwent open emergency surgical repair from 1990 to 2011 were included (463 patients; 374 [81%] male; mean age 74.7 ± 8.7years). Logistic and Cox regression analyses were performed to explore the association of variables with outcomes. Preoperatively, median (interquartile range) hemoglobin was 11.2 (9.5-12.8) g/dL, and median creatinine level was 140 (112-177) µmol/L. Intraoperatively, the median operative time was 2.25 (2-3) hours, and median estimated blood loss was 1.5 (0.5-3) L; 250 (54%) patients required intraoperative inotropes, and a median of 6 (4-8) units of blood was transfused. Median length of hospital stay was 11 (7-20) days. In-hospital mortality rate was 35.6%, and 5-year mortality was 48%. Age, distance traveled, operation duration, postoperative myocardial infarction (MI), and multi-organ failure (MOF) were predictors of in-hospital mortality and long-term outcome. Additionally, postoperative acute renal failure predicted in-hospital mortality. In patients with RAAA undergoing open surgical repair, the strongest predictors of in-hospital mortality and long-term outcome were postoperative MOF and MI and operative duration.

Association of Sex With Repair Type and Long-term Mortality in Adults With Abdominal Aortic Aneurysm

IMPORTANCE

Sex-based differences exist in the prevalence and clinical presentation of abdominal aortic aneurysm (AAA). However, it is unclear if sex is associated with AAA repair type and long-term mortality.

OBJECTIVE

To investigate whether a sex-related difference exists in mortality risk after AAA repair owing to differences in repair type.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study uses data from the Vascular Quality Initiative, a national clinical registry, and Medicare claims to investigate endovascular and surgical repair procedures performed between January 1, 2003, and September 30, 2015, in patients aged 65 years or older with AAA. The data were analyzed from October 1, 2018, to November 19, 2019.

EXPOSURE

Sex of the patient.

MAIN OUTCOMES AND MEASURES

Endovascular (EVR) or open surgical AAA repair type and subsequent long-term, all-cause mortality.

RESULTS

In this cohort study of 16 386 patients, 12 757 (77.9%) were men and 3629 (22.1%) were women. Women were more likely than men to be older (mean [SD] age, 77 [6.5] years vs 75 [6.6] years; P < .001), active smokers (33% vs 28%; P < .001), and to have smaller aneurysms (mean [SD] diameter, 57 [11.7] mm vs 59 [17.7] mm; P < .001). Surgical AAA repair was performed in 27% (983 of 3629) of women compared with 18% (2328 of 12 757) of men (P < .001). After inverse probability weighting for risk adjustment, women were more likely to receive open surgical repair than EVR repair (risk ratio, 1.65; 95% CI, 1.51-1.80). The 10-year unadjusted survival rate after EVR repair was 14% lower in women than in men (23% vs 37%; log-rank P < .001), but the rates were comparable after open surgical repair (36% in men vs 32% in women; log-rank P = .22). Risk-adjusted analysis showed that women were associated with higher mortality rates after EVR repair (hazard ratio, 1.13; 95% CI, 1.03-1.24), whereas both men and women had a similar risk of death after open surgical repair (hazard ratio, 0.94; 95% CI, 0.84-1.06). After further stratification by symptom severity, higher risk of mortality among women was limited to elective EVR and open surgical repair for ruptured AAA.

CONCLUSIONS AND RELEVANCE

In this study, women were 65% more likely than men to undergo open surgical repair. After EVR repair, women were 13% more likely to die than men, although no sex-based difference in mortality was found after open surgical repair. The differential treatment benefit of EVR repair in women is concerning given the shift toward an EVR-first approach to AAA repair.

LUCY results show females have equivalent outcomes to males following endovascular abdominal aortic aneurysm repair despite more complex aortic morphology

OBJECTIVE

Females remain underrepresented in studies of endovascular aneurysm repair (EVAR) owing to anatomic ineligibility for EVAR devices. The aim of the LUCY study is to explore the comparative safety and effectiveness of EVAR using a low-profile stent graft (Ovation; Endologix, Inc, Irvine, Calif) in females as well as males.

METHODS

The LUCY registry was a prospective, nonrandomized, multicenter study where patient enrollment was stratified by sex in a two-to-one ratio (male-to-female). Main outcomes were procedural data, 30-day major adverse events, device-related adverse events confirmed with contrast-enhanced computed tomography scans, secondary interventions, and hospital readmissions. Adverse events were adjudicated by a clinical events committee. Patients were followed at their 1-month and 1-year follow-up visits.

RESULTS

A total of 225 patients (76 females, 149 males) were enrolled at 39 U.S. centers. No statistically significant sex differences were observed in demographics or medical history. Females presented with smaller access vessels (6.2 vs 7.7 mm; P < .001), statistically smaller neck diameter (22 mm vs 23 mm; P = .001), similar neck angulation (11% vs 9% angulation >45°; P = .81), and smaller maximum abdominal aortic aneurysm (AAA) diameter (50 mm vs 53 mm; P = .01), however, these factors do not seem to be clinically significant. Technical success was 99%, and the median hospital stay was 1 day. The incidence of MAE through 30 days was 1.3% in females and 2.0% in males. There were no differences between sexes observed among the 30-day perioperative outcomes. The 30-day secondary intervention rate was 0.4%. The all-cause readmission rate through 30 days was 5.3% in females and 6.7% in males. There were no reports of limb occlusion or deaths within the first 30 days. At 1 year, there were no deaths in the female arm but nine deaths (6.0%) were observed in males, two of which were AAA related (1.3%). Through 1 year, there were eight type IA endoleaks (one female, seven males; P = .27) and three cases with limb occlusion (one female, two males). There were no reports of migration, AAA rupture, or surgical conversion through the end of follow-up.

CONCLUSIONS

Despite more complex aortic morphology in females than males, EVAR with a low-profile stent graft was associated with comparable procedural and perioperative outcomes through 1 year between the sexes.

Sex differences in Japanese patients with ruptured aortic aneurysms

OBJECTIVE

This study aimed to assess the sex differences in clinical presentation and outcomes of Japanese patients with ruptured aortic aneurysm (rAA) using a large nationwide claims-based database in Japan.

METHODS

We identified patients hospitalized in certified teaching hospitals in Japan with rAA between April 1, 2012, and March 31, 2015. Patients' characteristics and in-hospital outcomes were compared between men and women. The Barthel index was used for evaluating functional status at discharge by examining the ability to perform basic daily activities.

RESULTS

Of 7086 eligible patients, 32.3% (2291/7086) were women. Women were older than men (81.9 years vs 76.1 years; P < .001), had higher prevalence of coma at admission (33.2% vs 25.2%; P < .001), and were less likely to undergo emergency operation including endovascular aneurysm repair (35.7% vs 51.1%; P < .001). The unadjusted mortality rate (62.5% vs 52.0%; P < .001) and Barthel index at discharge (78.7 vs 86.1; P < .001) were significantly worse in women than in men. However, multilevel mixed-effect logistic regression analyses showed that female sex itself was not an independent predictor for in-hospital death (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.78-1.04; P = .17). Older age, coma at admission, and vasopressor use were detected as independent predictors for in-hospital death. The same results were confirmed for each rupture site. Stratified analyses showed that older women (threshold, 80 years; OR, 0.81; 95% CI, 0.66-0.98; P = .028) and those who underwent emergency operation (OR, 0.75; 95% CI, 0.61-0.93; P = .009) showed significantly better outcomes than men.

CONCLUSIONS

In a univariate analysis, female patients with rAA showed worse mortality than men because of their older age, more severe clinical presentation, and low emergency operation rate. However, after adjustment for covariates, female sex itself was not associated with increased mortality.

Sex differences in repair rates and outcomes of patients with ruptured abdominal aortic aneurysm

BACKGROUND

Data are conflicting on sex differences in ruptured abdominal aortic aneurysm (rAAA) repair rates and outcomes have rarely been addressed. The aim of this study was to investigate differences in the management and outcome of rAAA in men and women, and to describe time trends over a 15-year interval.

METHODS

Data on patients with rAAA were extracted from the Swedish National Patient Registry and the Cause of Death Registry for the interval 2001-2015. The study included patients with rAAA whether or not they were admitted to any hospital in Sweden. A propensity score-matched model was used to determine sex differences in repair type and outcome after rupture. Time trends for rAAA events and mortality were investigated.

RESULTS

Some 10 724 patients were identified. A higher percentage of men were admitted to hospital (79·8 versus 77·5 per cent; P = 0·011). Of those admitted, a higher percentage of men than women were treated (56·6 versus 40·4 per cent, P < 0·001). Women were less likely to be treated when diagnosed with rAAA (average treatment effect (ATE) in the model -0·080, 95 per cent c.i. -0·106 to -0·055; P < 0·001). Thirty-day mortality was also higher in women (ATE 0·094, 0·053 to 0·135; P < 0·001); this effect persisted to 1 year (ATE 0·095, 0·052 to 0·137; P < 0·001). Time trends indicated a decrease in rAAA incidence, mostly owing to a decrease among men.

CONCLUSION

In this study, fewer women with rAAA received surgery and 30-day mortality was higher than in men. There was an overall decrease in rAAA incidence, principally in men.

Prevalence of Elective and Ruptured Abdominal Aortic Aneurysm Repairs by Age and Sex From 2003 to 2016 in Ontario, Canada

IMPORTANCE

Age and sex are important considerations in assessing and individualizing therapy for abdominal aortic aneurysm (AAA) repair.

OBJECTIVE

To determine the prevalence of open and endovascular elective AAA (EAAA) and ruptured AAA (RAAA) repair by age and sex.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective, population-based, cross-sectional, time-series analysis in Ontario, Canada, from April 1, 2003, to March 31, 2016, all patients undergoing AAA repair who were older than 39 years were included.

EXPOSURES

Elective AAA and RAAA repair with open surgical repair (OSR) or endovascular aortic repair (EVAR).

MAIN OUTCOMES AND MEASURES

Age- and sex-standardized rates of EAAA and RAAA repair with OSR and EVAR.

RESULTS

From 2003 to 2016, 19 489 EAAA repairs (12 232 [63%] OSR and 7257 [37%] EVAR) and 2732 RAAA repairs (2466 [90%] OSR and 266 [10%] EVAR) were identified. The mean (SD) age was 72.7 (8.1) years in the EAAA subgroup and 73.5 (8.9) years in the RAAA subgroup; 15 813 patients (81%) in the EAAA subgroup and 2178 (80%) in the RAAA subgroup were men. The rates of EAAA by age quintile and sex decreased over the study period except among patients older than 79 years (1.3 per 100 000 population in 2003 to 2.2 per 100 000 population in 2016; 70% increase; P < .001). The rates of elective OSR decreased across all age and sex subgroups (range, 38%-74% decrease; P ≤ .009 for all subgroups) except among patients older than 79 years (1.3 per 100 000 population at baseline to 0.56 per 100 000 population in the second quarter of 2016; 53% decrease; P = .05). The rates of elective EVAR significantly increased across all age and sex subgroups (range, 566%-1585% increase; P ≤ .04 for all subgroups). Elective EVAR became the dominant treatment approach for aneurysms in men around 2010, whereas it maintained parity among women in 2016. The RAAA repair rate decreased over the study period in all subgroups (range, 32%-91% decrease; P ≤ .001 for all subgroups), but the decrease was not significant among women (80% decrease; P = .08). Similarly, the rates of ruptured OSR decreased among all subgroups (range, 47%-91% decrease; P < .001), but the decrease was not significant among women (87% decrease; P = .54). Ruptured EVAR showed significant uptake in all subgroups.

CONCLUSIONS AND RELEVANCE

Among patients with AAA in Ontario, Canada, use of EVAR appeared to increase from 2003 to 2016, whereas OSR use appeared to decrease. These findings were most pronounced among elective procedures for men and older patients. The delayed increase in the use of EVAR among women may reflect continued anatomical constraints for women seeking elective repair.

Gender differences in abdominal aortic aneurysm therapy - a systematic review

This article analyses if and to what extent gender differences exist in abdominal aortic aneurysm (AAA) therapy. For this purpose Medline (PubMed) was searched from January 1999 to January 2018. Keywords were: "abdominal aortic aneurysm", "gender", "prevalence", "EVAR", and "open surgery of abdominal aortic aneurysm". Regardless of open or endovascular treatment of abdominal aortic aneurysms, women have a higher rate of complications and longer hospitalizations compared to men. The majority of studies showed that women have a lower survival rate for surgical and endovascular treatment of abdominal aneurysms after both elective and emergency interventions. Women receive less surgical/interventional and protective medical treatment. Women seem to have a higher risk of rupture, a lower survival rate in AAA, and a higher rate of complications, regardless of endovascular or open treatment. The gender differences may be due to a higher age of women at diagnosis and therapy associated with higher comorbidity, but also because of genetic, hormonal, anatomical, biological, and socio-cultural differences. Strategies for treatment in female patients must be further defined to optimize outcome.

Gender differences in abdominal aortic aneurysms in Germany using health insurance claims data

Abstract. Background: Endovascular aortic repair (EVAR) has emerged as standard of care for abdominal aortic aneurysm (AAA). Real-world evidence is limited to compare this technology to open repair (OAR). Major gaps exist related to short-term and long-term outcomes, particularly in respect of gender differences. Materials and methods: Health insurance claims data from Germany’s third largest insurance provider, DAK-Gesundheit, was used to investigate invasive in-hospital treatment of intact (iAAA) and ruptured AAA (rAAA). Patients operated between October 2008 and April 2015 were included in the study. Results: A total of 5,509 patients (4,966 iAAA and 543 rAAA) underwent EVAR or OAR with a median follow-up of 2.44 years. Baseline demographics, comorbidities, and clinical characteristics of DAK-G patients were assessed. In total, 84.6 % of the iAAA and 79.9 % of the rAAA were male. Concerning iAAA repair, the median age (74 vs. 73 years, p < .001) compared to men was higher in females, but their EVAR-rate (66.8 % vs. 71.1 %, p = .018) was lower. Besides higher age of female patients (80 vs. 75 years, p < .001), no further statistically significant differences were seen following rAAA repair. In-hospital mortality was slightly lower in males compared to females following iAAA (2.3 % vs. 3.1 %, p = .159) and rAAA (37.3 % vs. 43.1 %, p = .273) repair. Concerning iAAA repair, a higher rate of female patients was transferred to another hospital (3.7 % vs. 2.0 %, p = 0.008) or discharged to rehabilitation (6.0 % vs. 2.7 %, p < .001) compared to male patients. Conclusions: In this large German claims data cohort, women are generally older and more often transferred to another hospital or discharged to rehab following iAAA repair. Nonetheless, no significantly increased risk of in-hospital or late death appeared for women in multivariate analyses. Further studies are necessary to evaluate the impact of recent gender-specific treatment strategies on overall outcome under real-world settings.

Persisting disparities between sexes in outcomes of ruptured abdominal aortic aneurysm hospitalizations

We sought to describe and analyze discrepancies between sexes in the outcomes of patients hospitalized for ruptured abdominal aortic aneurysms (rAAA) by conducting a retrospective analysis of the Nationwide Inpatient Sample. The review included all adult patients (≥18 years old) hospitalized with a primary diagnosis of rAAA between January 2002 and December 2014. In-hospital mortality differences between females and males were analyzed overall and separately among those receiving endovascular AAA repair (EVAR) or open AAA repair (OAR). In-hospital mortality for females declined from 61.0% in 2002 to 49.0% in 2014 (P for trend <0.001), while mortality for males declined from 48.6% in 2002 to 32.2% in 2014 (P for trend <0.001). Among those receiving EVAR, females were significantly more likely to die in the hospital than males (adjusted odds ratio [OR], 1.44; 95% CI, 1.12-1.84). In addition, the odds of mortality among those receiving OAR were higher for females than males (adjusted OR, 1.14; 95% CI: 1.00-1.31). These data provide evidence that despite overall decreasing trends in mortality for both sexes, females remain at higher risk of death compared with males regardless of surgical repair procedure.

A Majority of Admitted Patients With Ruptured Abdominal Aortic Aneurysm Undergo and Survive Corrective Treatment: A Population-Based Retrospective Cohort Study

Background

Abdominal aortic aneurysm (AAA) is an asymptomatic, potentially lethal condition predominantly found in elderly. The mortality is 100 % if rupture occurs and left untreated, but even in treated patients the mortality is substantial. Female sex and treatment with open repair rather than endovascular aortic repair (EVAR) have been reported to negatively affect outcome. The objective was to describe the contemporary care and outcome of all treated and untreated patients with ruptured AAA (rAAA) admitted to hospital.

Method

Population-based retrospective investigation, including all patients admitted to the emergency departments within Stockholm County diagnosed with rAAA 2009–2013. All identified patients’ charts (n = 297) were analyzed; the study cohort includes 283 verified patients.

Results

Men were in majority [214 (76 %), 69 (24 %) women] and were younger than women (78 vs 82 years, p < 0.001). A majority of patients were treated (212/283, 75 %), a similar proportion of women and men. Untreated patients had a higher mean age (84 vs 77 years, p < 0.001). The proportion treated with EVAR was 27 %, and they were older than OR treated (79 vs 76 years, p = 0.043). Forty-seven percentage of patients admitted with rAAA survived 30 days, and 62 % of treated patients survived 30 days. The 30-day mortality for women and men was similar.

Conclusions

Our results and other contemporary series show a shift toward a higher rate of treated patients with rAAA, and improving outcomes, similar for women and men. The increased use of EVAR contributes to this improvement in short-term outcome. High age influences the willingness to treat patients with rAAA.

Extended Serum Lipid Profile Predicting Long-Term Survival in Patients Treated for Abdominal Aortic Aneurysms

BACKGROUND

Individuals treated for abdominal aortic aneurysms (AAAs) are high-risk patients in whom better risk prediction could improve survival. Contemporary serum lipid parameters, such as apolipoproteins and lipoprotein subfractions, may improve or complement the prognostic value of traditional serum lipids. The aim of this study was to ascertain the extended serum lipid profiles, long-term prognosis and their association in AAA patients.

METHODS

Altogether 498 patients treated for AAAs and with available serum lipid values were retrospectively analysed. Contemporary lipid parameters were estimated using a neural network model, the extended Friedewald formula.

RESULTS

Younger age, smoking and urgent or emergency surgery were associated with an unfavourable, and coronary disease and previous stroke with a favourable lipid profile. In multivariable analysis-in addition to advanced age, aneurysm rupture, smoking, pulmonary disease and diabetes-high triglycerides and traditional LDL cholesterol were significant independent risk factors for mortality, HR 1.84 (95% CI 1.20-2.81) and 1.79 (95% CI 1.18-2.73), respectively, while higher EFW-IDL cholesterol was associated with better survival, HR 0.31 (95% CI 0.19-0.65). Including serum lipid parameters improved the prediction of 5-year survival (NRI = 17.7%, p = 0.016).

CONCLUSIONS

Extended serum lipid parameters complement risk prediction of patients treated for AAAs. An unfavourable lipid profile is associated with treatment of AAA earlier in life and with inferior long-term survival.

Abdominal aortic aneurysms in women

Abdominal aortic aneurysm (AAA) has long been recognized as a condition predominantly affecting males, with sex-associated differences described for almost every aspect of the disease from pathophysiology and epidemiology to morbidity and mortality. Women are generally spared from AAA formation by the immunomodulating effects of estrogen, but once they develop, the natural history of AAAs in women appears to be more aggressive, with more rapid expansion, a higher tendency to rupture at smaller diameters, and higher mortality following rupture. However, simply repairing AAAs at smaller diameters in women is a debatable solution, as even elective endovascular AAA repair is fraught with higher morbidity and mortality in women compared to men. The goal of this review is to summarize what is currently known about the effect of gender on AAA presentation, treatment, and outcomes. Additionally, we aim to review current controversies over screening recommendations and threshold for repair in women.

A multi-locus genetic risk score for abdominal aortic aneurysm

BACKGROUND

We investigated whether a multi-locus genetic risk scores (GRS) was associated with presence and progression of abdominal aortic aneurysm (AAA) in a case - control study.

METHODS AND RESULTS

The study comprised of 1124 patients with AAA (74 ± 8 years, 83% men, 52% of them with a maximal AAA size ≤ 5 cm) and 6524 non-cases (67 ± 11 years, 58% men) from the Mayo Vascular Disease Biorepository. AAA was defined as infrarenal abdominal aorta diameter ≥ 3.0 cm or history of AAA repair. Non-cases were participants without known AAA. A GRS was calculated using 4 SNPs associated with AAA at genome-wide significance (P ≤ 10(-8)). The GRS was associated with the presence of AAA after adjustment for age, sex, cardiovascular risk factors, atherosclerotic cardiovascular diseases and family history of aortic aneurysm: odds ratio (OR, 95% confidence interval, CI) 1.06 (1.04-1.09, p < 0.001). Adding GRS to conventional risk factors improved the association of presence of AAA (net reclassification index 14%, p < 0.001). In a subset of patients with AAA who had ≥ 2 imaging studies (n = 651, mean (SE) growth rate 2.47 (0.11) mm/year during a mean time interval of 5.41 years), GRS, baseline size, diabetes and family history were each associated with aneurysm growth rate in univariate association (all p < 0.05). The estimated mean aneurysm growth rate was 0.50 mm/year higher in those with GRS > median (5.78) than those with GRS ≤ median (p = 0.01), after adjustment for baseline size (p < 0.001), diabetes (p = 0.046) and family history of aortic aneurysm (p = 0.02).

CONCLUSIONS

A multi-locus GRS was associated with presence of AAA and greater aneurysm expansion.

Open Repair of Ruptured Abdominal Aortic Aneurysm: The Suitability of Endovascular Aneurysm Repair Does Not Influence Operative Mortality

Purpose:

We analyze the outcomes of open repair (OR) in patients with ruptured abdominal aortic aneurysm (RAAA) according to the anatomic suitability for endovascular aneurysm repair (EVAR).

Materials and Methods:

We reviewed retrospectively all consecutive RAAA patients who underwent OR from January 2005 to March 2014. All suspected patients underwent preoperative computed tomography (CT). Outcomes were major morbidities and mortality. Multivariate analysis was performed by using logistic regression adjusted by controlled variables; gender, Hardman index, maximal aneurysmal diameter, rupture type, perioperative transfusion requirement, and perioperative urinary output.

Results:

Among 54 consecutive patients with RAAA who underwent OR, 45 patients were included after exclusion of 9 patients (7, suprarenal; 1, infected; 1, inflammatory). Preoperative CT showed 27% (12/45) EVAR-suitable patients. Hostile neck anatomy was found in 88% (29/33) among unsuitable anatomy (UA) (n=33). The maximal aneurysmal diameter was statistically larger (83.1±21.0 mm vs. 68.8±12.3 mm, P=0.032) in the UA group. The 30-day mortality was 28.9% (13/45; 33% vs. 17% in UA group vs. suitable anatomy [SA] group, P=0.460; adjusted P=0.445). UA group had more patients with cardiac morbidity (55% vs. 25%, P=0.079; adjusted P=0.032; odds ratio, 12.914; 95% confidence interval, 1.238–134.675). There was no statistical difference in survival rate between SA and UA groups (74.1%, 74.1%, and 74.1% vs. 60.6%, 55.6%, and 32.4% at 1-, 3- and 5-year, respectively; P=0.145).

Conclusion:

In this study, relatively unfavorable outcomes were found in the EVAR-unsuitable group after OR in RAAA patients. However, unsuitable anatomy did not influence patient survival after OR by multivariate analysis.

Emerging strategies to treat ruptured abdominal aortic aneurysms

Population screening programmes and a falling population prevalence of smoking have led to a declining incidence of ruptured abdominal aortic aneurysms in men. However, ruptured abdominal aortic aneurysms remain a common vascular surgical emergency, with an increasing proportion of ruptures being in women. About one quarter of the ruptures have a juxta-renal aneurysm and are more challenging to repair using endovascular technologies. Endovascular technologies may not reduce the overall mortality, compared with open surgical repair, but appear to offer early benefits with respect to patient quality of life at acceptable cost. Challenges over the next 5 years include widening the access to repair, developing an accurate bedside risk scoring tool, as well as optimising strategies for pre-operative resuscitation, standardising peri-operative care and the management of post-operative complications.

National trends in incidence and outcomes of abdominal aortic aneurysm among elderly type 2 diabetic and non-diabetic patients in Spain (2003-2012)

BACKGROUND

This study aims to describe trends in the rate of abdominal aortic aneurysm (AAA) and use of open surgery repair (OSR) and endovascular aneurysm repair (EVAR) in elderly patients with and without type 2 diabetes in Spain, 2003-2012.

METHODS

We select all patients with a discharge of AAA using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. In both groups OSR and EVAR were identified. The incidence of discharges attributed to AAA were calculated overall and stratified by diabetes status and year. We calculated length of stay (LOHS) and in-hospital mortality (IHM). Use of OSR and EVAR were calculated stratified by diabetes status. Multivariate analysis was adjusted by age, sex, year, smoking habit and comorbidity.

RESULTS

From 2003 to 2012, 115,020 discharges with AAA were identified. The mean age was 74.91 years and 16.7% suffered type 2 diabetes. Rates of discharges due to AAA increased significantly in diabetic patients (50.09 in 2003 to 78.23 cases per 100,000 in 2012) and non diabetic subjects (69.24 to 78.66). The incidences were higher among those without than those with diabetes in all the years studied. The proportion of patients that underwent EVAR increased for both groups of patients and the open repair decreased. After multivariate analysis we found that LOHS and IHM have improved over the study period and diabetic patients had lower IHM than those without diabetes (OR 0.81; 95%CI 0.76-0.85).

CONCLUSIONS

Incidence rates were higher in non-diabetic patients. For diabetic and non diabetic patients the use of EVAR has increased and open repair seems to be decreasing. IHM and LOHS have improved from 2003 to 2012. Patients with diabetes had significantly lower mortality.

Epidemiology of ruptured abdominal aortic aneurysms in a well-defined Norwegian population with trends in incidence, intervention rate, and mortality

OBJECTIVE

Ruptured infrarenal abdominal aortic aneurysms (rAAAs) represent both a life-threatening emergency for the affected patient and a considerable health burden globally. The aim of this study was to investigate the contemporary epidemiology of rAAA in a defined Norwegian population for which both hospital and autopsy data were available.

METHODS

This was a retrospective, single-center population-based study of rAAA. The study includes all consecutively diagnosed prehospital and in-hospital cases of rAAA in the catchment area of Stavanger University Hospital between January 2000 and December 2012. Incidence and mortality rates (crude and adjusted) were calculated using national demographic data.

RESULTS

A total of 216 patients with primary rAAA were identified. The adjusted incidence rate for the study period was 11.0 per 100,000 per year (95% confidence interval [CI], 9.6-12.5). Twenty patients died out of the hospital, and 144 of the 196 patients (73%) admitted to the hospital underwent surgery. The intervention rate varied from 48% to 81% during the study period. The adjusted mortality rate was 7.5 per 100,000 per year (95% CI, 6.3-8.8). No differences in the incidence and mortality rates were found in comparing early and late periods. The 90-day standardized mortality ratio for the study period was 37.2 (95% CI, 31.6-43.7). The overall 90-day mortality was 68% (146 of 216 persons) and 51% (74 of 144 persons) for the patients treated for rAAA.

CONCLUSIONS

We found a stable incidence and mortality rate during a decade. The prehospital death rate was lower (9%), the intervention rate (73%) higher, and the total mortality (68%) lower than in most other studies. Geographic and regional differences may influence the epidemiologic description of rAAA and hence should be taken into consideration in comparing outcomes for in-hospital mortality and intervention rates.

Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA

BACKGROUND

The outcome of patients with ruptured abdominal aortic aneurysm (rAAA) varies by country. Study of practice differences might allow the formulation of pathways to improve care.

METHODS

We compared data from the Hospital Episode Statistics for England and the Nationwide Inpatient Sample for the USA for patients admitted to hospital with rAAA from 2005 to 2010. Primary outcomes were in-hospital mortality, mortality after intervention, and decision to follow non-corrective treatment. In-hospital mortality and the rate of non-corrective treatment were analysed by binary logistic regression for each health-care system, after adjustment for age, sex, year, and Charlson comorbidity index.

FINDINGS

The study included 11,799 patients with rAAA in England and 23,838 patients with rAAA in the USA. In-hospital mortality was lower in the USA than in England (53·05% [95% CI 51·26-54·85] vs 65·90%; p<0·0001). Intervention (open or endovascular repair) was offered to a greater proportion of cases in the USA than in England (19,174 [80·43%] vs 6897 [58·45%]; p<0·0001) and endovascular repair was more common in the USA than in England (4003 [20·88%] vs 589 [8·54%]; p<0·0001). Postintervention mortality was similar in both countries (41·77% for England and 41·65% for USA). These observations persisted in age-matched and sex-matched comparisons. In both countries, reduced mortality was associated with increased use of endovascular repair, increased hospital caseload (volume) for rAAA, high hospital bed capacity, hospitals with teaching status, and admission on a weekday.

INTERPRETATION

In-hospital survival from rAAA, intervention rates, and uptake of endovascular repair are lower in England than in the USA. In England and the USA, the lowest mortality for rAAA was seen in teaching hospitals with larger bed capacities and doing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients with rAAA.

FUNDING

None.

Evaluation of Medicare claims data to ascertain peripheral vascular events in the Women's Health Initiative

OBJECTIVE

Capturing long-term outcomes from large clinical databases by use of claims data is a potential strategy for improving efficiency while reducing study costs. We sought to compare the use of Medicare data with data from the Women's Health Initiative (WHI) to determine peripheral vascular events, as defined by the WHI study design.

METHODS

We studied participants from the WHI with both adjudicated outcomes and links to Medicare enrollment and utilization data through 2007. Outcomes of interest included hospitalizations for treatment of abdominal aortic aneurysm (AAA), lower extremity peripheral artery disease (LE PAD), and carotid artery stenosis (CAS). Events determined by WHI adjudication were compared with events defined by coding algorithms using diagnosis and procedure codes from Medicare data with a pilot data set and then validated with a test data set. We assessed agreement by a κ statistic and evaluated reasons for disagreement.

RESULTS

In the pilot set, records from 50,511 participants were analyzed. Agreement between the Centers for Medicare and Medicaid Services and WHI for admissions with a diagnosis but no treatment procedures for vascular conditions was poor (κ, 0.02-0.18). On the basis of WHI outcome data collection, vascular treatment procedures occurred in 29 participants for AAA, 204 for LE PAD events, and 281 for CAS. Medicare hospital claims recorded 41 treatments for AAA, 255 for LE PAD, and 317 for CAS. For participants with a Centers for Medicare and Medicaid Services-captured vascular procedure and a record adjudicated by WHI, κ values for treatment procedures were 0.81 for AAA, 0.77 for PAD, and 0.93 for CAS. For vascular procedures identified by WHI but not by Medicare hospital data (n = 82), 55% were captured by Medicare physician claims. Conversely, for treatments identified by Medicare hospital data but not captured by WHI adjudication (n = 57), 74% had physician claims consistent with the procedure. Fifteen participants with AAA or LE PAD procedures in hospital claims had medical records available for review, and nine of these had definitive documentation of procedures that were not captured by the WHI adjudication process. Estimated positive predictive value of Medicare data was 91% to 94% for AAA, 92% to 95% for LE PAD, and 94% to 99% for CAS. Available test set data (n = 50,253) yielded generally similar results with κ of 0.77 for AAA, 0.79 for LE PAD, and 0.94 for CAS.

CONCLUSIONS

Medicare data appear useful for identifying vascular treatment procedures for WHI participants. Medicare hospital claims identify more procedures than WHI does, with high positive predictive value, but also may not capture some procedures identified in WHI.

Relative importance of aneurysm diameter and body size for predicting abdominal aortic aneurysm rupture in men and women

OBJECTIVE

Women have been shown to have up to a fourfold higher risk of abdominal aortic aneurysm (AAA) rupture at any given aneurysm diameter compared with men, leading to recommendations to offer repair to women at lower diameter thresholds. Although this higher risk of rupture may simply reflect greater relative aortic dilatation in women who have smaller aortas to begin with, this has never been quantified. Our objective was therefore to quantify the relationship between rupture and aneurysm diameter relative to body size and determine whether a differential association between aneurysm diameter, body size, and rupture risk exists for men and women.

METHODS

We performed a retrospective review of all patients in the Vascular Study Group of New England (VSGNE) database who underwent endovascular or open AAA repair. Height and weight were used to calculate each patient's body mass index and body surface area (BSA). Next, indices of each measure of body size (height, weight, body mass index, BSA) relative to aneurysm diameter were calculated for each patient. To generate these indices, we divided aneurysm diameter (in cm) by the measure of body size; for example, aortic size index (ASI) = aneurysm diameter (cm)/BSA (m(2)). Along with other relevant clinical variables, we used these indices to construct different age-adjusted and multivariable-adjusted logistic regression models to determine predictors of ruptured repair vs elective repair. Models for men and women were developed separately, and different models were compared using the area under the curve.

RESULTS

We identified 4045 patients (78% male) who underwent AAA repair (53% endovascular aortic aneurysm repairs). Women had significantly smaller diameter aneurysms, lower BSA, and higher BSA indices than men. For men, the variable that increased the odds of rupture the most was aneurysm diameter (area under the curve = 0.82). Men exhibited an increased rupture risk with increasing aneurysm diameter (<5.5 cm: odds ratio [OR], 1.0; 5.5-6.4 cm: OR, 0.9; 95% confidence interval [CI], 0.5-1.7; P = .771; 6.5-7.4 cm: OR, 3.9; 95% CI, 1.9-1.0; P < .001; ≥ 7.5 cm: OR, 11.3; 95% CI, 4.9-25.8; P < .001). In contrast, the variable most predictive of rupture in women was ASI (area under the curve = 0.81), with higher odds of rupture at a higher ASI (ASI >3.5-3.9: OR, 6.4; 95% CI, 1.7-24.1; P = .006; ASI ≥ 4.0: OR, 9.5; 95% CI, 2.3-39.4; P = .002). For women, aneurysm diameter was not a significant predictor of rupture after adjusting for ASI.

CONCLUSIONS

Aneurysm diameter indexed to body size is the most important determinant of rupture for women, whereas aneurysm diameter alone is most predictive of rupture for men. Women with the largest diameter aneurysms and the smallest body sizes are at the greatest risk of rupture.

Ruptured abdominal aortic aneurysm: the state of play

BACKGROUND

Ruptured abdominal aortic aneurysm (rAAA) remains a challenging problem: 2,410 cases were treated in Germany in 2010. Ruptured abdominal aortic aneurysm should be suspected in patients over age 50 who complain of pain in the abdomen or back and in whom examination reveals a pulsatile abdominal mass. The incidence of hospitalization for rAAA is 12 per 100,000 persons over age 65 per year (statistics for Germany, 2010), and rAAA carries an overall mortality of 80%.

METHODS

The current state of knowledge of rAAA was surveyed in a selective review of pertinent literature retrieved by an electronic search in the PubMed, Web of Science, and Cochrane Library databases with the keywords "abdominal aortic aneurysm," "ruptured," "open repair," and "endovascular." Publications in English or German up to and including March 2012 were considered, among them the Clinical Practice Guidelines of the European Society for Vascular Surgery (1).

RESULTS AND CONCLUSIONS

Recent reports show that the treatment of rAAA is still fraught with high mortality and high perioperative morbidity. Improvement is needed. It would be advisable for the care of rAAA to be centralized in specialized vascular centers implementing defined treatment pathways. Systematic screening, too, would be beneficial. An increasing number of reports suggest that endovascular treatment with stent prostheses improves outcomes; more definitive evidence on this matter will come from prospective, randomized trials that are now in progress.

Early and mid-term results of a prospective observational study comparing emergency endovascular aneurysm repair with open surgery in both ruptured and unruptured acute abdominal aortic aneurysms

The aim of the paper is to prospectively describe early and mid-term outcomes for emergency endovascular aneurysm repair (eEVAR) versus open surgery in acute abdominal aortic aneurysms (aAAAs), both unruptured (symptomatic) and ruptured. We enrolled all consecutive patients treated for aAAA at our center between April 2002 and April 2008. The main outcome parameters were 30-day, 6- and 12-month mortality (all-cause and aneurysm-related). Two hundred forty patients were enrolled in the study. In the unruptured aAAA group ( n = 111), 47 (42%) underwent eEVAR. The 30-day, 6- and 12-month mortality rates were 6, 13 and 15% in the eEVAR group versus 11% (NS), 13% (NS) and 16% (NS) in the open group, respectively. In the ruptured aAAA group ( n = 129), 25 (19%) underwent eEVAR (mortality rates: 20, 28 and 36%, respectively) compared with 104 (81%) patients who underwent open surgery (mortality rates: 45% ( P = 0.021), 60% ( P = 0.004) and 63% ( P = 0.014), respectively). In conclusion, the present study showed a reduced 30-day, 6- and 12-month mortality of eEVAR compared with open surgery in all patients with aAAA, mainly due to a lower mortality in the ruptured aAAA group. Late aneurysm-related mortality occurred only in the eEVAR group.

Examining sex and gender disparities in total joint arthroplasty

BACKGROUND

Total joint arthroplasty (TJA) is remarkably successful for treating osteoarthritis: most patients see substantial gains in function. However, there are considerable geographic, racial, and gender variations in the utilization of these procedures. The reasons for these differences are complex.

QUESTIONS/PURPOSES

We examined sex and gender disparities in TJA.

METHODS

Through Medline/PubMed searches, we identified 632 articles and from these selected 61 for our review. WHERE ARE WE NOW?: A number of factors might explain sex and gender disparities in TJA: underrepresentation in clinical trials, differences in willingness to undergo surgery, pain responses to underlying disease and treatment, patient-physician relationships, treatment preferences, provider-level factors such as physician-patient communication style, and system-level factors such as access to specialist care. Since women have a higher prevalence of arthritis and degenerative joint diseases and overall demand for these procedures will continue to grow, the need to understand why there is a gap in utilization based on gender is imperative. WHERE DO WE NEED TO GO?: Understanding what exactly is meant by "disparity" is essential because it is possible anatomic factors may have different impacts on utilization from cultural factors. Ideally, information about these factors should be integrated into the decision-making process so that patients and providers can make the most informed choice about whether or not to undergo the procedure. HOW DO WE GET THERE?: To better understand all of the potential reasons for how anatomic and cultural factors related to sex and gender might impact decision-making and overall utilization of TJA, more research focusing on these factors must be designed and carried out.

Reproductive history in women with abdominal aortic aneurysms

BACKGROUND

The prevalence of abdominal aortic aneurysms (AAAs) differs considerably between the sexes, illustrated by the male/female ratio 4-6:1. Women are also reported to have a higher risk of rupture, and a poorer outcome compared with men. The primary aim of this study was to investigate if women with AAA have a different reproductive history compared with other women. The secondary aim was to study if women with a larger AAA differ in their reproductive history from women with a smaller AAA.

METHOD

This case-control study was performed in October 2009 and included 140 consecutively monitored women with AAA and 140 with peripheral arterial disease (PAD) at the Department of Vascular Surgery at Karolinska University Hospital, Stockholm. AAA was defined as AAA diameter >3 cm, and women with AAA were subdivided into groups with AAA diameter ≥5 cm and diameter <5 cm. A validated questionnaire was used to obtain information about participants' reproductive history and general health. The response rate was 70% (n = 196).

RESULTS

Women with AAA were smokers to a greater extent than women with PAD (previous, 52% vs 46%; current, 46% vs 34%, P = .001). Diabetes mellitus was more prevalent in women with PAD (28%) than in women with AAA (15%, P = .034). Angina pectoris occurred more often in women with AAA (26%) than in women with PAD (11%, P = .026). No significant difference was found between PAD and AAA women regarding statin use, treatment for hypertension, prior myocardial infarction, and body mass index (BMI). The 54 women with AAA ≥5 cm and the 44 women with AAA <5 cm were similar in age (76 vs 76 years, P = .908) and BMI (25.7 vs 24.0 kg/m(2), P = .66). No difference was noted in the occurrence of other risk factors between women with AAA ≥5 cm and women with AAA <5 cm. Mean age at menopause was lower in women with AAA ≥5 cm than in women with AAA <5 cm and in women with PAD (47.7 vs 49.9 vs 49.7 years, P = .011). Apart from menopausal age, the groups had a similar reproductive history, including hormone replacement therapy, parity, use of contraceptives, prior gynecological surgery, and breast cancer.

CONCLUSION

These findings suggest that women with larger AAA reach menopausal age earlier, and this could influence an earlier onset of aneurysmatic disease or an increase in aneurysm growth. The true role of endogenous estrogen in aneurysm development and expansion is yet to be investigated.

Effect of gender on long-term survival after abdominal aortic aneurysm repair based on results from the Medicare national database

OBJECTIVES

Historically, women have higher procedurally related mortality rates than men for abdominal aortic aneurysm (AAA) repair. Although endovascular aneurysm repair (EVAR) has improved these rates for men and women, effects of gender on long-term survival with different types of AAA repair, such as EVAR vs open aneurysm repair (OAR), need further investigation. To address this issue, we analyzed survival in matched cohorts who received EVAR or OAR for both elective (eAAA) and ruptured AAA (rAAA).

METHODS

Using the Medicare Beneficiary Database (1995-2006), we compiled a cohort of patients who underwent OAR or EVAR for eAAA (n = 322,892) or rAAA (n = 48,865). Men and women were matched by propensity scores, accounting for baseline demographics, comorbid conditions, treating institution, and surgeon experience. Frailty models were used to compare long-term survival of the matched groups.

RESULTS

Perioperative mortality for eAAAs was significantly lower among EVAR vs OAR recipients for both men (1.84% vs 4.80%) and women (3.19% vs 6.37%, P < .0001). One difference, however, was that the survival benefit of EVAR was sustained for the 6 years of follow-up in women but disappeared in 2 years in men. Similarly, the survival benefit of men vs women after elective EVAR disappeared after 1.5 to 2 years. For rAAAs, 30-day mortality was significantly lower for EVAR recipients compared with OAR recipients, for both men (33.43% vs 43.70% P < .0001) and women (41.01% vs 48.28%, P = .0201). Six-year survival was significantly higher for men who received EVAR vs those who received OAR (P = .001). However, the survival benefit for women who received EVAR compared with OAR disappeared in 6 months. Survival was also substantially higher for men than women after emergent EVAR (P = .0007).

CONCLUSIONS

Gender disparity is evident from long-term outcomes after AAA repair. In the case for rAAA, where the long-term outcome for women was significantly worse than for men, the less invasive EVAR treatment did not appear to benefit women to the same extent that it did for men. Although the long-term outcome after open repair for elective AAA was also worse for women, EVAR benefit for women was sustained longer than for men. These associations require further study to isolate specific risk factors that would be potential targets for improving AAA management.

Trends in incidence and mortality from abdominal aortic aneurysm in New Zealand

BACKGROUND

This study examined trends in abdominal aortic aneurysm (AAA) incidence and mortality in New Zealand (NZ) and compared these with mortality rates from England and Wales.

METHODS

Cause-specific death data were obtained from the NZ Ministry of Health, UK Office for National Statistics and National Archives (for England and Wales). The NZ National Minimum Data Set provided hospital discharge data from July 1994 to June 2009.

RESULTS

In 2005-2007 the age-standardized AAA mortality rate for men was 33·3 per cent less in NZ than in England and Wales (5·21 versus 7·81 per 100 000), whereas for women it was 9·8 per cent less (2·12 versus 2·35 per 100 000). Standardized mortality rates in NZ fell by 53·0 per cent for men and 34·1 per cent for women from 1991 to 2007. Between 1991-1992 and 2005-2007 the probability of a 65-year-old dying from an AAA fell by 28·2 per cent (from 1·872 to 1·344 per cent) in men, and by 6·3 per cent (from 0·837 to 0·784 per cent) in women. New AAA admission and hospital death rates in NZ peaked in 1999 for men, and in 2001 for women, and have since declined sharply. Hospital mortality ratios have also fallen, except for women with a ruptured aneurysm.

CONCLUSION

The burden of AAA disease has been falling since at least 1991 in NZ, and since 1995 in England and Wales. Although survival appears to be improving, most of the reduction is due to lower disease incidence.