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October 17, 2008
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Nick N Abedi*, Daniel L Davenport*, Eleftherios Xenos, Ehab Sorial, David J Minion, Eric D Endean
University of Kentucky, Lexington, KY
BACKGROUND: Prior studies have demonstrated higher in-hospital mortality in women undergoing open abdominal aortic aneurysm repair. The current study evaluates the effect of gender on 30-day outcomes for endovascular aneurysm repair (EVAR) in a multi-center, contemporary patient population.
METHODS: All patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent EVAR of abdominal aortic and/or iliac artery aneurysms (AAA) in the calendar years 2005-2007 were identified through use of CPT codes. Preoperative risk factors, intra-operative variables, and 30-day outcome measures were tabulated. Composite morbidity included patients experiencing one or more of 21 complications defined by the NSQIP protocol. T-tests and analyses of variance (ANOVA) were used to compare variables by gender.
RESULTS: 3,801patients underwent EVAR including: tube grafts (360, 9.5%); bifurcated, one docking limb (1,624, 42.7%); bifurcated, two docking limbs (1,294, 34.0%); unibody (218, 5.7%); aorto-uni-iliac/femoral (166, 4.4%); and iliac (139, 3.7%) repair. EVAR patients included 664 (17.5%) women and 3,137 (82.5%) men with mean ages of 74.8 years and 73.6 years (p=0.001). Overall 30-day morbidity and mortality was 11.8% and 2.1%, respectively. Morbidity in women was significantly higher than men (18.1% vs. 10.5%; p<0.001). Likewise mortality was higher in women (3.5% vs. 1.8%; p=0.007). Significant differences existed in preoperative variables (Table), but no gender differences were noted in rates of prior myocardial infarction (MI), angina, hypertension, or congestive heart failure (CHF). Among the postoperative complications, women had significantly higher rates of need to return to the OR (9.3% vs. 4.8%; p<0.001), superficial wound infection (3.5% vs. 1.8%; p=0.003), unplanned intubation (3.2% vs. 1.5%; p=0.028), ventilation for greater than 48 hours (4.5% vs. 2.0%; p<0.001), graft failure (2.3% vs. 1.1%; p=0.019), and postoperative transfusion (2.3% vs. 0.7%; p<0.001). Length of stay was significantly longer in women (5.21 days vs. 3.67 days; p<0.001). Regarding intra-operative variables, women had more emergency operations (6.8% vs. 4.3, p=0.007), longer operative times (182.6 minutes vs. 161.7 minutes; p<0.001) and more blood transfusion (0.89 units vs. 0.39 units; p<0.001). After adjustment for the top 12 NSQIP risk factors for 30-day mortality after vascular surgery, women continued to have a higher risk for death (Odds ration 1.85, p=0.044)
CONCLUSIONS: While overall morbidity and mortality for EVAR is low, women have higher rates of complications and death compared to men. These findings may, in part, be due to the higher pulmonary and infectious complications seen in women. Additionally, women had higher pulmonary risk factors (COPD, current smoking) and had fewer interventions for cardiac disease preoperatively despite similar cardiac histories for MI, angina, hypertension and CHF. The fact that women had higher intra-operative transfusion requirements and longer operative times suggests that EVAR is more difficult in women than men. Appropriate patient selection, identification and treatment of preoperative co-morbid conditions, and attention to anatomic factors that can make EVAR more difficult may result in improved outcomes for women undergoing EVAR.
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The Effect of Gender on 30-day Outcomes for Endovascular Repair of Abdominal Aortic and Iliac Artery Aneurysms
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Nick N Abedi*, Daniel L Davenport*, Eleftherios Xenos, Ehab Sorial, David J Minion, Eric D Endean
University of Kentucky, Lexington, KY
BACKGROUND: Prior studies have demonstrated higher in-hospital mortality in women undergoing open abdominal aortic aneurysm repair. The current study evaluates the effect of gender on 30-day outcomes for endovascular aneurysm repair (EVAR) in a multi-center, contemporary patient population.
METHODS: All patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent EVAR of abdominal aortic and/or iliac artery aneurysms (AAA) in the calendar years 2005-2007 were identified through use of CPT codes. Preoperative risk factors, intra-operative variables, and 30-day outcome measures were tabulated. Composite morbidity included patients experiencing one or more of 21 complications defined by the NSQIP protocol. T-tests and analyses of variance (ANOVA) were used to compare variables by gender.
RESULTS: 3,801patients underwent EVAR including: tube grafts (360, 9.5%); bifurcated, one docking limb (1,624, 42.7%); bifurcated, two docking limbs (1,294, 34.0%); unibody (218, 5.7%); aorto-uni-iliac/femoral (166, 4.4%); and iliac (139, 3.7%) repair. EVAR patients included 664 (17.5%) women and 3,137 (82.5%) men with mean ages of 74.8 years and 73.6 years (p=0.001). Overall 30-day morbidity and mortality was 11.8% and 2.1%, respectively. Morbidity in women was significantly higher than men (18.1% vs. 10.5%; p<0.001). Likewise mortality was higher in women (3.5% vs. 1.8%; p=0.007). Significant differences existed in preoperative variables (Table), but no gender differences were noted in rates of prior myocardial infarction (MI), angina, hypertension, or congestive heart failure (CHF). Among the postoperative complications, women had significantly higher rates of need to return to the OR (9.3% vs. 4.8%; p<0.001), superficial wound infection (3.5% vs. 1.8%; p=0.003), unplanned intubation (3.2% vs. 1.5%; p=0.028), ventilation for greater than 48 hours (4.5% vs. 2.0%; p<0.001), graft failure (2.3% vs. 1.1%; p=0.019), and postoperative transfusion (2.3% vs. 0.7%; p<0.001). Length of stay was significantly longer in women (5.21 days vs. 3.67 days; p<0.001). Regarding intra-operative variables, women had more emergency operations (6.8% vs. 4.3, p=0.007), longer operative times (182.6 minutes vs. 161.7 minutes; p<0.001) and more blood transfusion (0.89 units vs. 0.39 units; p<0.001). After adjustment for the top 12 NSQIP risk factors for 30-day mortality after vascular surgery, women continued to have a higher risk for death (Odds ration 1.85, p=0.044)
CONCLUSIONS: While overall morbidity and mortality for EVAR is low, women have higher rates of complications and death compared to men. These findings may, in part, be due to the higher pulmonary and infectious complications seen in women. Additionally, women had higher pulmonary risk factors (COPD, current smoking) and had fewer interventions for cardiac disease preoperatively despite similar cardiac histories for MI, angina, hypertension and CHF. The fact that women had higher intra-operative transfusion requirements and longer operative times suggests that EVAR is more difficult in women than men. Appropriate patient selection, identification and treatment of preoperative co-morbid conditions, and attention to anatomic factors that can make EVAR more difficult may result in improved outcomes for women undergoing EVAR.
| Risk Factor | Women | Men | p value |
| Pack year history of smoking | 35.34 pk yr | 42.32 pk yr | <0.001 |
| Current smoking | 35.8% | 28.1% | <0.001 |
| History of COPD | 23.0% | 17.8% | 0.002 |
| Prior coronary angioplastsy | 15.5% | 20.6% | 0.003 |
| Prior cardiac surgery | 14.5% | 27.0% | <0.001 |
| Current alcohol use | 1.2% | 4.5% | <0.001 |
| Albumin | 3.79 mg/dl | 3.87 mg/dl | 0.014 |
| Creatinine >1.2 mg/dl | 22% | 34% | <0.001 |
| Hematocrit <38% | 45.0% | 26.0% | <0.001 |
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