Mortality following elective abdominal aortic aneurysm repair in women

Q: What are the key findings of this study?

Female sex was significantly associated with higher perioperative mortality after elective abdominal aortic aneurysm repair compared to male sex (3.0% vs 1.5%; adjusted OR 1.68, p=0.003).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Abdominal aortic aneurysm (AAA) undergoing primary elective repair (n=12034). Intervention: Female sex vs. Male sex. Primary outcome: Perioperative mortality (in-hospital and/or 30-day mortality) (OR 1.68, 95% CI 1.20-2.37, p=0.003).

Q: What does this research mean for the field?

Female sex is independently associated with an increased risk of perioperative mortality following elective abdominal aortic aneurysm repair, regardless of patient- and hospital-related factors. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Victoria N. Tedjawirja; Anna J. Alberga; Michel H. Hof; A.C. Vahl; Mark J.W. Koelemay; Ron Balm; P.J. Van den Akker; G.J. Akkersdijk; G.P. Akkersdijk; W.L. Akkersdijk; M.G. van Andringa de Kempenaer; C.H. Arts; J.A. Avontuur; Olaf J. Bakker; Ron Balm; W.B. Barendregt; Joost A. Bekken; M.H. Bender; B.L. Bendermacher; M. van den Berg; P. Berger; R.J. Beuk; J.D. Blankensteijn; R.J. Bleker; Joris J. Blok; A.S. Bode; M.E. Bodegom; K.E. van der Bogt; A.P.M. Boll; M.H. Booster; B.L. Borger van der Burg; Gert J. de Borst; W.T.G.J. Bos- van Rossum; Hans Bosma; J.M. Botman; L.H. Bouwman; V. Brehm; M.T. de Bruijn; Jorg L. de Bruin; P. Brummel; J.P. van Brussel; S.E. Buijk; Manon Buijs; M.G. Buimer; D.H. Burger; H.C.J.L. Buscher; E. Cancrinus; P.H. Castenmiller; G. Cazander; Ariane Coester; P.H. Cuypers; J. H. C. Daemen; I. Dawson; J.E. Dierikx; Martijn Dijkstra; J. Diks; M.K. Dinkelman; M. Dirven; D.E. Dolmans; R.C. van Doorn; L.M. van Dortmont; J.W. Drouven; M.M. van der Eb; D. Eefting; G.J. van Eijck; Jan-Willem Elshof; B.H. Elsman; A. van der Elst; M.I. van Engeland; R.G. van Eps; M.J. Faber; W.M. de Fijter; Bram Fioole; Talje M. Fokkema; F.A. Frans; W.M. Fritschy; Pingping Jin; Robert H. Geelkerken; W.B. van Gent; G.J. Glade; B. Govaert; R.P. Groenendijk; H.G. de Groot; R.F. van den Haak; E.F. de Haan; G.F. Hajer; J.F. Hamming; E.S. van Hattum; C.E. Hazenberg; P.P. Hedeman Joosten; Jozien Helleman; L.G. van der Hem; Jeroen Hendriks; Joost A. van Herwaarden; Jan M.M. Heyligers; Jan-Willem Hinnen; R.J. Hissink; Gwan H. Ho; P.T. den Hoed; M.T. Hoedt

doi:10.1093/bjs/znab465

December 22, 2021British journal of surgeryOpen Access

Mortality following elective abdominal aortic aneurysm repair in women

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Key result

Female sex is linked to ~68% higher perioperative mortality after elective AAA repair.

OR 1.68
95% CI 1.20-2.37
P=0.003
n=12,034

Figures

Why the study?

Previous studies focused on patient-related factors for higher mortality in women undergoing elective AAA repair; whether hospital-related factors influence outcomes remained unknown.

Does female sex increase the risk of in-hospital and/or 30-day mortality following elective abdominal aortic aneurysm repair after adjusting for patient-related and hospital-level volume factors?

Key Points

To evaluate whether hospital-related factors influence the increased mortality risk observed in women undergoing elective abdominal aortic aneurysm repair.
Nationwide registry study of 12 034 patients (1780 women and 10 254 men) undergoing elective abdominal aortic aneurysm repair across 61 hospitals in the Netherlands (Dutch Surgical Aneurysm Audit, 2013–2018).
Mixed-effects logistic regression analysis assessed the effect of sex on in-hospital and/or 30-day mortality, incorporating a hospital-specific random effect and adjusting for patient-related factors and hospital volumes of open surgical repair (OSR) and endovascular aneurysm repair (EVAR).
Perioperative mortality was higher in women than in men: 53 of 1780 (3.0 per cent) versus 152 of 10 254 (1.5 per cent) overall (P < 0.001), as well as after OSR (38 of 550 [6.9 per cent] versus 104 of 2277 [4.6 per cent]; P = 0.024) and EVAR (15 of 1230 [1.2 per cent] versus 48 of 7977 [0.6 per cent]; P = 0.014).
Female sex remained significantly associated with mortality after adjustment for patient- and hospital-related factors (OR 1.68, 95 per cent c.i. 1.20 to 2.37; P = 0.003).
Higher hospital OSR volume was associated with lower mortality (OR 0.91, 95 per cent c.i. 0.85 to 0.95 per 10-procedure increase), whereas higher EVAR volume showed an OR of 1.03 (1.01 to 1.05) per 10-procedure increase.

Study Design

Type

Cohort (n=12,034)

Multicenter

Yes

Structured PICO

Does female sex increase the risk of in-hospital and/or 30-day mortality following elective abdominal aortic aneurysm repair after adjusting for patient-related and hospital-level volume factors?

P

Population

12,034 adults (14.8% female; mean age 74.1 years in women and 73.1 years in men) undergoing primary elective open or endovascular abdominal aortic aneurysm repair across 61 hospitals in the Netherlands, followed for 30 days and/or in-hospital.

E

Exposure

Female sex (evaluated as a risk factor alongside hospital OSR and EVAR procedural volumes and patient-related risk factors)

C

Comparator

Male sex

O

Outcome

Perioperative mortality, comprising in-hospital mortality during primary admission and/or 30-day mortalityhard clinical

Main Result

Odds Ratio: 1.68 (95% CI 1.2–2.37)

Absolute Event Rate: 3% vs 1.5%

p-value: p=0.003

Women undergoing elective abdominal aortic aneurysm repair face an independently higher risk of 30-day/in-hospital mortality compared to men, even after adjusting for baseline comorbidities, type of repair, and hospital procedural volumes.

Limitations

Unmeasured patient- and hospital-related risk factors not registered in the DSAA (such as aneurysm anatomy, operative complexity, surgeon volume, and social factors like caregiver status) could not be taken into account.
Retrospective study using data from a quality registry not primarily designed for research.
Missing values in approximately 8% of patients (though <4% for each individual co-morbidity).
Ruptured AAA procedures were excluded from the calculation of hospital volume, which may not have reflected full expertise at tertiary referral centres.
Potential risk factors not registered in the DSAA could not be accounted for, including aneurysm anatomy, operative complexity, surgeon volume, and social factors such as caregiver status.
Retrospective design using data from a quality registry not primarily designed for research.
Missing values distributed over approximately 8% of patients (<4% for each co-morbidity), requiring complete-case analysis.
Ruptured AAA procedures were not included in the calculation of hospital volume.

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Implication

Persistent sex disparity in elective AAA repair mortality after volume adjustment; extends observational data and supports further research into modifiable factors.

Abstract

BACKGROUND: Previous studies have focused on patient-related risk factors to explain the higher mortality risk in women undergoing elective abdominal aortic aneurysm (AAA) repair. The aim of this study was to evaluate whether hospital-related factors influence outcomes following AAA repair in women. METHODS: Patients undergoing elective AAA repair in 61 hospitals in the Netherlands were identified from the Dutch Surgical Aneurysm Audit registry (2013-2018). A mixed-effects logistic regression analysis was conducted to assess the effect of sex on in-hospital and/or 30-day mortality. This analysis accounted for possible correlation of outcomes among patients who were treated in the same hospital, by adding a hospital-specific random effect to the statistical model. The analysis adjusted for patient-related risk factors and hospital volume of open surgical repair (OSR) and endovascular aneurysm repair (EVAR). RESULTS: Some 12 034 patients were included in the analysis. The mortality rate was higher in women than among men: 53 of 1780 (3.0 per cent) versus 152 of 10 254 (1.5 per cent) respectively. Female sex was significantly associated with mortality after correction for patient- and hospital-related factors (odds ratio 1.68, 95 per cent c.i. 1.20 to 2.37). OSR volume was associated with lower mortality (OR 0.91 (0.85 to 0.95) per 10-procedure increase) whereas no such relationship was identified with EVAR volume (OR 1.03 (1.01 to 1.05) per 10-procedure increase). CONCLUSION: Women are at higher risk of death after abdominal aortic aneurysm repair irrespective of patient- and hospital-related factors.

Discussion

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Cite This Study

Tedjawirja et al. (2021) conducted a cohort in Abdominal aortic aneurysm (AAA) undergoing primary elective repair (n=12,034). Female sex vs. Male sex was evaluated on Perioperative mortality (in-hospital and/or 30-day mortality) (OR 1.68, 95% CI 1.20-2.37, p=0.003). Female sex was significantly associated with higher perioperative mortality after elective abdominal aortic aneurysm repair compared to male sex (3.0% vs 1.5%; adjusted OR 1.68, p=0.003).

synapsesocial.com/papers/6a7d91191a9d4ca5f9ac7a1a https://doi.org/10.1093/bjs/znab465

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Mortality following elective abdominal aortic aneurysm repair in women

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Mortality following elective abdominal aortic aneurysm repair in women

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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