Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass.
Division of Vascular and Endovascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
J Vasc Surg. 2020 Apr;71(4):1179-1189. doi: 10.1016/j.jvs.2019.05.065. Epub 2019 Aug 30.
Women with abdominal aortic aneurysms less often meet anatomic criteria for endovascular repair and experience worse perioperative and long-term survival.
We compared long-term survival, aneurysm-related mortality, and rates of endoleaks and reinterventions between male and female patients in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) using 2:1 propensity score matching.
There were 1130 male patients and 133 female patients, yielding 399 patients after matching (266 male patients, 133 female patients). Female patients were older, with smaller aneurysms, smaller iliac arteries, and shorter, more angulated necks, and they were more often treated outside the device instructions for use (all P < .001). Through 5 years, female patients experienced overall mortality comparable to that of well-matched male patients (34% vs 38%, respectively; hazard ratio, 0.89 [0.61-1.29]; P = .54) and lower aneurysm-related mortality (0% vs 3%; P = .047). Female patients experienced higher rates of any postoperative type IA endoleak through 5 years (10% vs 1%; P < .001) but comparable rates of secondary endovascular procedures (14% vs 16%; P = .40). Female sex was independently associated with significantly higher risk of long-term type IA endoleaks (hazard ratio, 4.8 [1.2-20.8]; P = .04), even after accounting for anatomic factors. No female patient experienced aneurysm rupture during follow-up, and only one female patient underwent conversion to open repair.
Despite more challenging anatomy, female patients in the ENGAGE registry had long-term outcomes comparable to those of male patients. However, female patients experienced higher rates of type IA endoleaks. Although standard endovascular aneurysm repair remains a viable solution for most women, whether high-risk patients may be better served with open surgery, custom-made devices, EndoAnchors (Aptus Endosystems, Sunnyvale, Calif), or chimneys is worthy of further study.
患有腹主动脉瘤的女性患者较少符合血管内修复的解剖标准，并且在围手术期和长期生存方面的预后更差。
我们通过 2:1 倾向评分匹配，比较了 Endurant 支架移植物自然选择全球上市后注册研究（ENGAGE）中男性和女性患者的长期生存、与动脉瘤相关的死亡率，以及内漏和再干预的发生率。
共有 1130 名男性患者和 133 名女性患者，匹配后得到 399 名患者（266 名男性患者，133 名女性患者）。女性患者年龄较大，动脉瘤较小，髂动脉较小，颈部更短、更弯曲，且更多地在器械使用说明之外接受治疗（所有 P 值均<.001）。在 5 年时，女性患者的总死亡率与匹配良好的男性患者相当（分别为 34%和 38%；风险比，0.89[0.61-1.29]；P=.54），而动脉瘤相关死亡率更低（0%比 3%；P=.047）。女性患者在 5 年内任何类型的术后 I 型内漏的发生率更高（10%比 1%；P<.001），但二次血管内治疗的发生率相似（14%比 16%；P=.40）。女性性别与长期 I 型内漏的风险显著增加独立相关（风险比，4.8[1.2-20.8]；P=.04），即使考虑到解剖因素也是如此。在随访期间，没有女性患者发生动脉瘤破裂，仅有 1 名女性患者转为开放修复。
尽管女性患者的解剖结构更具挑战性，但在 ENGAGE 注册研究中，她们的长期结局与男性患者相当。然而，女性患者发生 I 型内漏的比例更高。虽然标准血管内动脉瘤修复仍然是大多数女性患者的可行治疗方法，但高危患者是否可以通过开放手术、定制设备、EndoAnchors（Aptus Endosystems，加利福尼亚州森尼韦尔）或烟囱技术获得更好的治疗效果，值得进一步研究。
