Endovascular abdominal aortic aneurysm repair: does gender matter?

Substantial differences across genders have been documented for the natural history and clinical course of cardiovascular diseases. This study's objective is to compare preoperative characteristics, intraoperative events, and postoperative outcomes in men and women undergoing endovascular abdominal aortic aneurysm repair (EVAR). We hypothesized that despite gender anatomic specificities, EVAR may achieve similar results across genders. We included 241 consecutive patients who underwent elective EVAR at our institution from December 1996 through May 2003. Demographic variables and comorbidities were collected by chart review, and intraoperative events were from surgical notes. Baseline anatomic characteristics were evaluated on the last preoperative computed tomography (CT) scan. Radiologic outcomes were evaluated on all postoperative CT scans, and clinical follow-up information was abstracted from charts. Women constituted 12% (n = 29) of our cohort and were older than men (79.9 vs. 74.9 years, p = 0.0003). When compared to men, they had aneurysms with similar diameter (54.1 vs. 55.5 mm, p = 0.491) but narrower (23.1 vs 25.5 mm, p < 0.0001) and shorter (18.9 vs. 30.4 mm, p < 0.0001) proximal necks. Female iliac arteries were narrower (9.6 vs. 11.4 mm, p < 0.0001), with higher calcification scores (2.5 vs. 2.3, p = 0.047) but lower tortuosity indexes (1.2 vs. 1.3, p = 0.0001). Additional access maneuvers were more frequent in women: iliac access angioplasty (31% vs. 10.9%, = p = 0.007), uni-iliac conversion (13.8% vs. 1.4%, p = 0.005), and iliac "chimney" conduit (12.1% vs. 1.2%, p = 0.0001). There was a trend toward longer fluoroscopy time in women (34.6 vs. 26.9 min, p = 0.056). The following postoperative outcomes at 24 months were similar in women and men: freedom from endoleak (63.4% vs. 72.7%, p = 0.74), reintervention rate (28% vs. 24.5%, p = 0.878), aneurysm shrinkage (24.3% vs. 68.7%, p = 0.199), aneurysm expansion (0% vs. 3%, p = 0.213), and survival (92.9% vs. 84.3%, p = 0.341). There was a trend toward higher rates of neck dilation relative to preoperative diameter in women (48.5% vs. 16% at 12 months, p = 0.059) and toward lower limb patency rates in men (100% vs. 92.8%, p = 0.098). In sum, women have shorter proximal necks and smaller and more calcified iliac arteries, which increases the necessity of access-related additional maneuvers. Despite being older and having a less favorable anatomy, women can expect similar technical and clinical outcomes after EVAR.