Sex differences in outcomes of a two-stage approach to aortic arch surgery: 8-year experience of a national aortovascular centre

Hybrid surgery for aortic arch pathology consisting of a combined frozen elephant trunk (FET) and endovascular (TEVAR) treatment, confers a good prognosis with excellent outcomes. It is known that females, who often have higher risk profiles and more advanced disease at presentation, confer a worse prognosis post cardiac surgery compared to their male counterparts. We compare our outcomes of male and female patients after a two-stage approach. Demographic, survival and outcome data were retrospectively analysed in patients undergoing two-staged FET and endovascular surgery between January 2018 and January 2025. 32 patients with mean age 60.8 years, underwent a two-stage surgery (endovascular N = 18 (56.2%) vs. open thoracoabdominal approach N = 14 (43.8%) 2nd stage)). 16 males (50%), with comparable demographics. Indications for FET surgery: incidence of chronic type A dissections were similar but females had fewer chronic type B dissections (2 vs. 9; p = 0.02; 0.1[0.02–0.6]); and more aneurysms (13 vs. 8; p = 0.14; 4.3[0.9–17.8]. Overall mortality: No in-hospital or 90-day mortality. Overall survival (OS) at 5-years was 87.1% vs. 77.9% for males and females respectively (p = 0.76). Complications: Females had more returns to theatre (4 vs. 2; p = 0.65; 2.3 [0.4–13.4]). LOS 16.0 vs. 13.5 days for males vs. females respectively (p = 0.54). 2nd stage surgery: Median interval between operations: 240 (males) vs. 140 days (females). OS correlated positively with increasing intervals in both males (p = 0.79; r = 0.07) and females (0.29; r-0.28). Overall complications were comparable. Females had more spinal ischaemia (7 vs. 3; p = 0.25; 3.3 [0.7–14]; but fewer females required renal replacement therapy (2 vs. 4; p = 0.65; 0.4[0.07–2.3]. Survival and complications are comparable in males and females, with good long-term results, therefore a two-stage approach should be offered to all patients along with aortovascular multidisciplinary team (MDT) surveillance. Larger studies are required to validate our results.