A systematic review and meta-analysis on early mortality after abdominal aortic aneurysm repair in females in urgent and elective setting

OBJECTIVE

Females represent a group of patients with higher mortality after abdominal aortic aneurysm (AAA), endovascular (EVAR) or open (OSR), repair. This systematic review aimed to evaluate the 30-day mortality after AAA repair in females, comparing both EVAR and OSR, in elective and urgent settings.

METHODS

The protocol of the review was registered to the PROSPERO (CRD42021242686). A search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, from inception to March 5, 2021, using the Systematic Reviews and Meta-Analysis guidelines (PRISMA). Only studies reporting on 30-day mortality of AAA repair, in urgent and elective setting, comparing EVAR and OSR, in female population were eligible. Patients were stratified according to the need for elective or urgent repair. Symptomatic and ruptured cases were included into the urgent group. Individual studies were assessed for risk of bias using the ROBINS-I tool. The GRADE approach was used to evaluate the quality of evidence. The primary outcome was 30-day mortality after AAA repair in the female population, comparing EVAR and OSR. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis.

RESULTS

Eight studies reported data on 30-day mortality following AAA repair. A total of 56,982 females (22,995 EVAR vs. 33,987 OSR) were included. A significantly reduced total 30-day mortality rate was recorded among females that underwent EVAR compared to OSR (OR, 0.25; 95% CI, 0.23-0.27; P<.001, Ι²=86%). Also a reduced 30-day mortality was found in females that underwent elective EVAR compared to OSR (OR, 0.37; 95% CI, 0.33-0.41; P< .001, Ι²=48%). Despite that OSR was more frequently offered in the urgent setting (OR, 0.21; 95% CI, 0.19-0.23; P< .001, Ι²=84%), EVAR was associated with a reduced 30-day mortality (OR, 0.48; 95% CI, 0.40-0.57; P<.001, Ι²=0%).

CONCLUSIONS

In females, EVAR is associated with lower 30-day mortality in both elective and urgent AAA repair, although it appears as less likely to be offered in the setting of urgent AAA repair.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of Sex on Outcomes After Thoracic Endovascular Repair for Type B Aortic Dissection

We aimed to investigate whether sex differences influence the clinical outcomes of patients who undergo thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). We retrospectively analyzed a prospectively maintained single-center cohort of patients with TBAD who underwent TEVAR between January 2010 and June 2017. We evaluated the in-hospital and long-term mortality and composite end point. Of the 913 patients, 793 (86.8%) were male and 120 (13.1%) were female. Compared to male patients, the female patients were older, more likely to have diabetes mellitus, but less likely to smoke or have hypertension. The proximal landing zone in 0 and 1 was higher in male patients (P = .023), who were more likely to require an aortic arch bypass. Endoleak, delirium, and ICU stay after stent-graft implantation were also more frequent in men. Sex factor was not associated with in-hospital or long-term mortality or the composite end point in the multivariable regression analyses and Cox regression model. The mean estimated survival time was similar between males and females (2462.9 ± 141.2 vs 2804.1 ± 117.4 days, P = .167) in the propensity score-matched cohort. Despite distinct characteristics between sex, there was no sex-related difference in long-term clinical outcomes after TEVAR for TBAD.

Top 10 candidate aortic disease trials

Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced unprecedented technical and medical developments in the field. Despite this, there is a great need, and great opportunities, to further explore the area. In this review, we have identified important areas that need to be further studied and selected priority aortic disease trials. There is a pressing need to update the AAA natural history and the role for endovascular AAA repair as well as to define biomarkers and genetic risk factors as well as influence of gender for development and progression of aortic disease. A key limitation of contemporary treatment strategies of AAA is the lack of therapy directed at small AAA, to prevent AAA expansion and need for surgical repair, as well as to reduce the risk for aortic rupture. Currently, the most promising potential drug candidate to slow AAA growth is metformin, and RCTs to verify or reject this hypothesis are warranted. In addition, the role of endovascular treatment for ascending pathologies and for uncomplicated type B aortic dissection needs to be clarified.

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.

Complex endovascular treatment of intact aortic aneurysms: An analysis of health insurance claims data

Background

The complex endovascular repair of aortic aneurysms and dissections with fenestrated or branched stent grafts (FB-EVAR) remains challenging for interventional vascular surgery. To date, the evidence regarding treatment patterns and outcome measures consists of single center studies; however, it might be reasonable to validate results with multicenter real-world evidence.

Methods

Health insurance claims data from Germany’s third largest insurance provider, DAK-Gesundheit, were used to determine outcomes following FB-EVAR of non-ruptured thoracic aorta (TA) or thoracoabdominal including pararenal abdominal (TAA) aorta. The study included patients operated between January 2008 and April 2017.

Results

Included were 984 patients (18.1% female) who underwent FB-EVAR. Patients with treatment of the TA were younger (71.7 vs. 73.2 years, p < 0.001) and more often female (38.5% vs. 17.0%, p < 0.001) as compared to patients with treatment of TAA. In the TA group peripheral arterial disease was less frequent compared to the TAA group (67.3% vs. 80.4%, p = 0.036). Mortality was significantly (p < 0.001) higher following repair of the TAA compared to the TA at discharge (17.3% vs. 4.6%), at 30 days (26.9% vs. 8.2%) and at 90 days (34.6% vs. 10.1%). Patients with treatment of the TAA suffered more often from stroke as compared to the TA group (7.7% vs. 1.2%, p = 0.002).

Conclusion

In this large-scale German analysis of claims data, multicenter real-world evidence was different from single center studies regarding patient risk-factors and outcome measures. Validated multicenter registry studies could help to further investigate this topic in times of increasing procedures.