Women have Higher Morbidity and Mortality Following Repair of Complex Aortic Aneurysms Due to Symptomatic Presentation and More Extensive Aneurysms.

Objective: Prior studies have found disparities in outcomes by sex following repair of abdominal aortic aneurysms. However, little is known about the disparities in outcomes following endovascular repair of complex abdominal aortic aneurysms. This study aims to assess differences in presentation and outcomes by sex following endovascular repair of complex abdominal aortic aneurysms.

Methods: All patients treated via endovascular approach for complex abdominal aortic aneurysms treated in the Vascular Quality Initiative database from 2014-2022 were included. Demographics, comorbidities, and operative details were compared by sex. Perioperative outcomes and long-term survival were then assessed using univariable and adjusted analysis.

Results: 4671 patients were treated for complex abdominal aortic aneurysms, including 74% men and 26% women. Women had higher rates of chronic obstructive pulmonary disease (46% vs. 38%, p<0.001), but lower rates of coronary artery disease (20% vs. 32%, p<0.001) and lower baseline creatinine (0.9 vs. 1.1, p<0.001). Women more commonly presented symptomatic (18% vs. 9%), ruptured (2.9% vs. 2.0%), and had more thoracoabdominal aneurysms (vs. juxtarenal) (38% vs. 26%) on presentation than men (all p<0.001). Women had higher thirty-day mortality (5.2% vs. 2.8%, p<0.001) and long-term mortality (p<0.001) compared to men. This trend persisted after adjustment for thirty-day mortality (OR 1.5, CI: 1.0-2.2) but not long-term survival (HR 1.2, CI: 0.96-1.4). Prior to adjustment, major morbidities were also more common among women, including cardiac complications (12% vs. 10%, p=0.024), respiratory complications (7.0% vs. 4.2%, p<0.001), intestinal ischemia (2.8% vs. 1.5%, p=0.005), stroke (2.6% vs. 1.2%, p=0.002), and spinal cord ischemia (5.3% vs. 3.3%, p=0.002). Prolonged length of stay exceeding 7 days was also more common among women (25% vs. 14%, p<0.001). Only prolonged length of stay (OR 1.7, CI: 1.4-2.1) was more common among women following adjustment. Rather, non-elective repair (OR 1.9, CI: 1.5-2.3) and thoracoabdominal extent (OR 1.3, CI: 1.1-1.6) was associated with late mortality.

Conclusions: Women experience higher morbidity and mortality following endovascular repair of complex abdominal aortic aneurysms, primarily due to urgent presentations and more extensive aneurysms at time of repair. These findings highlight the critical need for improved screening and earlier intervention in women, which may help mitigate this inequality and improve outcomes.