Sex Differences in Outcomes After Endovascular Abdominal Aortic Aneurysm Repair: A Systematic Review and Narrative Synthesis

Background: Abdominal aortic aneurysm (AAA) is less prevalent in women, yet rupture occurs owing to smaller diameters, leading to higher mortality rates; moreover, higher mortality rates also occur in women after aneurysm repair procedures. Meanwhile, whether women derive comparable benefit from endovascular aneurysm repair (EVAR) remains uncertain, partly because of anatomical constraints, such as smaller-caliber access vessels and more angulated proximal necks. This review evaluates sex-specific perioperative and long-term outcomes after EVAR. Methods: This study was conducted as a systematic review with narrative synthesis, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 framework. A comprehensive search was conducted in the PubMed/MEDLINE and Scopus databases for studies published between January 2000 and September 2025. Search strings combined controlled vocabulary and free-text terms for “abdominal aortic aneurysm”, “endovascular aneurysm repair”, and “sex” or “gender” or “female”. A predefined Population, Intervention, Comparison, Outcome (PICO) model was used to guide study selection. Comparative observational cohorts, registry or claims analyses, and EVAR-focused meta-analyses reporting sex-stratified outcomes were eligible. Articles were restricted to English. Outcomes included perioperative mortality, major complications, reintervention, and long-term survival. Given the heterogeneity and the availability of recent pooled analyses, quantitative synthesis favored adjusted estimates from high-quality meta-analyses and registries, and no new pooled meta-analysis was performed to avoid data duplication. Results: A total of 15 studies met the inclusion criteria, encompassing more than 500,000 EVAR procedures. Women consistently exhibited higher early mortality and morbidity after standard infrarenal EVAR. The largest EVAR-focused meta-analysis reported an odds ratio (OR) for 30-day mortality of 1.73 (95% confidence interval (CI) 1.32–2.26) and in-hospital mortality OR of 1.90 (1.43–2.53) for women versus men, with increased risks of limb ischemia (~2.4-fold), renal (OR ~1.7), and cardiac complications (OR ~1.7). Long-term all-cause mortality was higher in women (hazard ratio (HR) 1.23, 95% CI 1.09–1.38). Contemporary registry data indicated similar adjusted mortality but persistently greater access-related morbidity in women, including higher rates of limb ischemia (5.3% vs. 3.2%) and major bleeding (22.0% vs. 15.9%). Perioperative mortality and complications were approximately two-fold higher in women following complex EVAR, defined as fenestrated and/or branched endovascular repair (F/BEVAR) for juxtarenal, pararenal, suprarenal, or thoracoabdominal aneurysms. Additionally, survival remained inferior in those with a ruptured AAA (8-year survival: 36.7% vs. 49.5%). Conclusions: Women undergoing EVAR continue to experience higher perioperative morbidity and less favorable long-term outcomes compared with men, despite advances in device technology and perioperative care. These disparities largely reflect anatomical and physiological differences, delayed presentation, and underrepresentation in clinical trials and registries. This systematic review and narrative synthesis clarifies sex-specific differences in outcomes after standard infrarenal EVAR and complex F/BEVAR, integrating evidence from contemporary device eras. Sex-aware imaging, individualized access planning, and device design tailored to smaller anatomy are critical to achieving equitable outcomes in endovascular aortic repair.