Early Versus Threshold Repair of Women’s Abdominal Aortic Aneurysms

BACKGROUND: Guidelines recommend elective repair of women's abdominal aortic aneurysms (AAAs) at an aortic diameter ≥5.0 cm, based on limited female data. This study evaluates outcomes of elective repair for small (4-4.99 cm) versus larger (≥5.0 cm) asymptomatic AAAs in women. METHODS: Using Vascular Quality Initiative registry data, we performed a retrospective cohort analysis of 15,544 women ≥50 years undergoing elective open or endovascular aneurysm repair (EVAR) from 2010-2023. Propensity scores were estimated within repair strata and applied as stabilized inverse-probability-of-treatment weights (IPTW). Primary outcomes were all-cause mortality (IPTW-weighted Cox), Kaplan-Meier survival at 12/24/36/48/60 months, restricted mean survival time (RMST, bootstrap), 30-day mortality, and postoperative cardiovascular and cerebrovascular complications. Secondary outcomes included hospitalization length, endoleak, and odds of open repair. RESULTS: IPTW-weighted Cox models revealed AAAs ≥5.0 cm versus 4-4.99 cm were associated with higher adjusted all-cause mortality in the EVAR cohort (hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.05-1.37; Open HR 1.47, 95% CI 0.99-2.16). Sixty-month weighted survival was lower for larger AAAs (EVAR: 79.7% vs 82.8%; Open: 82.3% vs 87.1%). RMST to 60 months favoured treatment at 4-4.99 cm. Thirty-day mortality, hospitalization length, and postoperative cardiovascular and cerebrovascular complications were similar by diameter. Larger AAAs had higher odds of endoleak (odds ratio (OR) 1.35, 95% CI 1.19-1.53) and of undergoing open repair (OR 1.80, 95% CI 1.56-2.09). CONCLUSION: Among women, asymptomatic AAAs ≥5.0 cm were associated with modestly lower 5-year survival and greater odds of endoleak. These findings support individualized decision-making rather than a single diameter cutoff.