Influence of gender on outcomes after thoracic endovascular aneurysm repair

Objective: Previous studies have shown that female gender is associated with increased morbidity and mortality after endovascular abdominal aortic aneurysm repair. The goal of this study was to assess the effect of gender on 30-day outcomes after thoracic endovascular aortic aneurysm repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods: This was a review of the 2005 to 2011 ACS-NSQIP database to identify all patients who underwent TEVAR for nonruptured thoracic aortic aneurysms. Procedure and diagnosis codes were used to capture the study population. Patients were stratified according to gender. Baseline, operative, and outcomes data were compared in bivariate fashion. The primary outcome measure was 30-day mortality, and a risk-adjusted generalized linear model with Poisson distribution was used to identify relative risk.

Results: During the study period, 649 patients, 279 women (43%) and 370 men (57%), underwent TEVAR. Baseline demographics according to gender were similar; however, women were less likely to drink alcohol (1% vs 5%; P = .001) and to have a history of cardiac surgery (14% vs 27%; P < .001). More women required iliac artery exposure (18% vs 7%; P < .001). Operative times (173.6 ± 6.3 vs 159.8 ± 5.2 minutes; P = .03), transfusion rates (30% vs 17%, P = .001), and hospital length of stay (7.7 ± 0.5 vs 7.6 ± 0.5 days; P = .009) were increased in women compared with men. Overall, postoperative complications were similar, but unadjusted mortality was significantly greater in women (6% vs 3%; P = .03). On multivariable analysis, female gender was no longer a significant predictor of mortality (relative risk [RR], 2.30; 95% confidence interval [CI], 0.99-5.34; P = .053). Independent predictors of 30-day mortality included increasing age (RR, 1.05; 95% CI, 1.01-1.09; P = .02), emergency procedure (RR, 3.76; 95% CI, 1.79-7.87; P < .001), and iliac artery exposure (RR, 4.42; 95% CI, 2.07-9.44; P < .001).

Conclusions: Thirty-day unadjusted mortality after TEVAR for nonruptured thoracic aortic aneurysms is increased in women compared with men, but this univariate finding did not persist after risk adjustment. Multivariable analysis showed need for iliac artery exposure, age, and emergency surgery were independently associated with higher mortality rates. These results suggest a need for decreased device delivery size and improvements in endovascular technology.