Sex difference in early mortality after abdominal aortic aneurysm repair

Predicting 30-day Mortality after Ruptured Abdominal Aortic Aneurysms: Validation of the Harborview Risk Score in a Single-Center Dutch Study Population

BACKGROUND

The Harborview Risk Score (HRS) was recently proposed as scoring tool to predict 30-day mortality in patients with ruptured abdominal aortic aneurysms (rAAAs). The HRS assigns 1 point for each of the following preoperative characteristics: age > 76 years, pH < 7.2, creatinine level > 2 mg/dL (> 176.8 μmol/L), and systolic blood pressure < 70 mm Hg, resulting in scores from 0 to 4. The 30-day mortality risk increases with every point. Primarily, we aimed to validate the HRS for the first time in a Dutch study population. A second objective was to identify other clinically relevant predictors for 30-day mortality after repair of rAAA.

METHODS

Retrospective data from patients who underwent open repair or endovascular aortic repair for a rAAA between January 2009 and February 2022 were reviewed. Patients were grouped by HRS category (score 0-4). The 30-day mortality rate was calculated for each HRS category. Determinants for 30-day mortality were tested for significance and validated for HRS.

RESULTS

In total, data from 135 patients were included. Open repair was performed in 95 patients and 40 patients underwent endovascular aortic repair. Univariate logistic regression identified pH < 7.2, systolic blood pressure < 70 mm Hg, female sex, performance status, and increase per HRS unit as significant determinants for 30-day mortality. After adjusting for sex and performance status in the multivariate analysis, the association between the HRS per-unit increase and 30-day mortality remained significant (odds ratio 2.532 (95% confidence interval: 1.437-4.461)). The 30-day mortality rate for HRS score 0 was 15.2%, while for HRS score 3 and 4 the mortality was 80% and 100% respectively.

CONCLUSIONS

The Harborview Risk Score was validated in this single-center Dutch population. Results were concordant with data presented in earlier studies. Therefore, the HRS seems accurate and accessible as preoperative tool. For now, the HRS should guide as an insightful tool to indicate the chances of postoperative mortality during the preoperative conversations in the emergency room, rather than as a decision-making tool whether to operate or not. Our results suggest that female sex and performance status are also relevant predictors that should be assessed in other populations to improve preoperative scoring systems.

Sex disparities in popliteal artery aneurysms

OBJECTIVE

Only 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe's largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented.

METHODS

POPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form.

RESULTS

Of the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions.

CONCLUSIONS

Women have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Association of women-specific size threshold and mortality in elective abdominal aortic aneurysm repair

BACKGROUND

It is unclear whether women derive mortality benefit from early repair of abdominal aortic aneurysms (AAA). The aim of this study was to compare short- and mid-term mortality for women treated at small versus large diameters.

METHOD

Women receiving elective repair of AAA at small (49-54 mm) and large (≥55 mm) diameters from 2008 to 2022 were extracted from the Swedish National Registry for Vascular Surgery (n = 1642 women). The effect of diameter on 90-day, 1- and 3-year mortality was studied in logistic regression and propensity score models. Age, co-morbidities, smoking and repair modality were considered as confounders. Men (n = 9047) were analysed in parallel.

RESULTS

Some 1642 women were analysed, of whom 34% underwent repair at small diameters (versus 52% of men). Women with small (versus large) AAAs were younger (73 versus 75 years, P < 0.001), and 63% of women in both size groups had endovascular repairs (P = 0.120). Mortality was 3.5% (90 days), 7.1% (1 year) and 15.8% (3 years), with no differences between the size strata. There was no consistent association between AAA size and mortality in multivariable models. Sex differences in mortality were almost entirely due to mortality in younger-than-average women versus men (3-year mortality: small AAAs 11.1% versus 7.3%, P < 0.030, or large 14.4% versus 10.7%, P < 0.038).

CONCLUSION

Mortality in women is high and unaffected by AAA size at repair. The optimal threshold for women remains undefined. The higher rupture risk in women should not automatically translate into a lower, women-specific threshold.