Sex-Related Outcomes Following Endovascular Repair of Thoracoabdominal Aortic Aneurysm

OBJECTIVE Previous studies have suggested unique challenges in treating women with thoracoabdominal aortic aneurysms (TAAA) compared to their male counterparts. We sought to examine the real-world outcomes of complex endovascular repair (cEVAR) for TAAA in women and men. METHODS Patients undergoing cEVAR for type I-IV TAAAs between 2014-2020 were identified using the Vascular Quality Initiative (VQI) database. Demographic, preoperative, and intraoperative variables, as well as postoperative outcomes were compared between women and men. One-year survival following cEVAR was compared between women and men using the long-term follow up data from VQI. RESULTS A total of 1128 patients underwent cEVAR for type I-IV TAAAs during the study period, of whom 417 (37%) were females. Women had more extensive aneurysms (84.7% vs 72.4% type I-III TAAA; P<0.001) and were more likely to present with symptomatic aneurysm (26.1% vs 18.4%; P=0.002) compared to men. Women were less likely to be on secondary cardiovascular preventative medications, including aspirin (59.4% vs 67.4%; 0.019) and statins (65.1% vs 73.1%; P=0.012), more likely to be current smokers (36.1% vs 30.7%; P=0.052), and treated at higher maximum diameter threshold (7.7 vs 4.6mm above recommended repair size; P<0.001). While there were no differences in operative time, women were more likely to have undergone a staged repair (22.3% vs 16.6%; P=0.018) and have complicated iliofemoral access (19.2% vs 10.3%; P<.001) with higher incidence of access complications (8.9% vs 5.2%; P=0.016) compared to men. Thirty-day rates of mortality (11.8% vs 6.6%; P=0.003) and overall complication (35.7% vs 25.7%; P<.001), including permanent spinal cord ischemia (5.5% vs 2.8%; P=0.022) primarily among patients with type II TAAAs (7.8 vs 3.0%; P=0.025), were all higher for women compared to men. One-year survival following cEVAR for TAAAs were significantly lower for women compared to men (74 vs 82%; P=0.001), driven by the higher 30-day mortality rate in women. Female sex was an independent risk factor for both 30-day and 1-year mortality. CONCLUSIONS This study demonstrated that women had higher 30-day morbidity and mortality and lower 1-year survival following cEVAR of type I-IV TAAA compared to men. There were significant differences in presentation, anatomic features, and implementations of secondary cardiovascular preventative management, all likely affecting the differences in outcomes between women and men. Future studies are warranted to better understand these differences and optimize sex-specific approach to management of TAAAs in women.