Complex Aortic Team, Division of Vascular Surgery, Royal Free NHS Foundation Trust, London, United Kingdom.
Complex Aortic Team, Division of Vascular Surgery, Royal Free NHS Foundation Trust, London, United Kingdom; Division of Surgery and Interventional Science, University College London, London, United Kingdom.
J Vasc Surg. 2020 Mar;71(3):748-757. doi: 10.1016/j.jvs.2019.05.053. Epub 2019 Aug 30.
A rational approach to the management of aortic aneurysm disease relies on weighing the risk of aneurysm rupture against the complications and durability of operative repair. In men, seminal studies of infrarenal aortic aneurysm disease and its endovascular management can provide a reasoned argument for the timing and modality of surgery, which is then extrapolated to the management of thoracoabdominal aortic aneurysms (TAAAs). In contrast, there is less appreciation for the natural history of TAAA disease in women and its response to therapy.
We used a retrospective cohort design of women, all men, and matched men, fit for complex endovascular thoracoabdominal aneurysm repair at two large aortic centers. We controlled for preoperative anatomic and comorbidity differences, and assessed technical success, postoperative renal dysfunction, spinal ischemia, and early mortality. Women and matched men were reassessed at follow-up for long-term durability and survival.
Assessing women and all men undergoing complex endovascular aortic reconstruction, we demonstrate that these groups are dissimilar before the intervention with respect to comorbidities, aneurysm extent, and aneurysm size; women have a higher proportion of proximal Crawford extent 1, 2, and 3 aneurysms. Matching men and women for demographic and anatomic differences, we find persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aneurysm repair compared with matched men (6%); however, at the 3-year follow-up, both groups have the same survival. Furthermore, women demonstrate more favorable anatomic responses to aneurysm exclusion, with good durability and greater aneurysm sac regression at follow-up, compared with matched men.
Women and unmatched men with TAAA disease differ preoperatively with respect to aneurysm extent and comorbidities. Controlling for these differences, after complex endovascular aneurysm repair, there is increased early mortality in women compared with matched men. These observations argue for a careful risk stratification of women undergoing endovascular thoracoabdominal aneurysm treatment, balanced with women's good long-term survival and durability of endovascular aneurysm repair.
主动脉瘤疾病的管理需要权衡瘤体破裂的风险与手术修复的并发症和耐久性。在男性中，对肾下主动脉瘤疾病及其血管内治疗的深入研究可以为手术时机和方式提供合理的依据，然后将这些依据外推至胸腹主动脉瘤（TAAA）的治疗。相比之下，女性 TAAA 疾病的自然病史及其对治疗的反应尚未得到充分认识。
我们使用了回顾性队列设计，纳入了在两个大型主动脉中心接受复杂血管内胸腹主动脉瘤修复的女性、男性和匹配的男性患者。我们控制了术前解剖和合并症差异，并评估了技术成功率、术后肾功能障碍、脊髓缺血和早期死亡率。女性和匹配的男性在随访中评估长期耐久性和生存率。
在评估接受复杂血管内主动脉重建的女性和所有男性时，我们发现这些组在干预前就存在合并症、瘤体范围和瘤体大小方面的差异；女性近端 Crawford 程度 1、2 和 3 型瘤体的比例更高。通过匹配女性和男性的人口统计学和解剖差异，我们发现女性（16%）在接受血管内胸腹主动脉瘤修复的围手术期死亡率高于匹配的男性（6%）；然而，在 3 年随访时，两组的生存率相同。此外，与匹配的男性相比，女性对瘤体排除的解剖反应更好，在随访时具有更好的耐久性和更大的瘤体囊腔缩小。
患有 TAAA 疾病的女性和未匹配的男性在术前就存在瘤体范围和合并症方面的差异。在控制这些差异后，与匹配的男性相比，女性在复杂血管内动脉瘤修复后早期死亡率更高。这些观察结果表明，在对接受血管内胸腹主动脉瘤治疗的女性进行仔细的风险分层时，需要平衡女性良好的长期生存和血管内动脉瘤修复的耐久性。
