Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA; Medical Scientist Training Program, University of Washington, Seattle, WA.
Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
J Vasc Surg. 2022 Jul;76(1):61-69.e3. doi: 10.1016/j.jvs.2022.01.145. Epub 2022 Feb 25.
Operative repair of thoracoabdominal aortic aneurysms (TAAAs) is high risk, and many patients will be unfit for intervention. Prior studies have noted lower rates of repair for women than for men. The reasons for this disparity have remained unknown but could include a greater burden of co-morbid illness or anatomic barriers. Frailty could also contribute to the lower intervention rates but has rarely been reported in preoperative risk assessments. The aim of the present study was to assess the sex-related differences in clinical comorbidities, anatomic suitability, and frailty among an unselected cohort of patients who had presented with TAAAs.
All patients with extent I to V TAAAs confirmed by computed tomography imaging between 2009 and 2019 at a single institution were reviewed. Patients were included regardless of whether they had undergone repair. Clinical comorbidities, anatomic details, and metrics of frailty were collected and used to determine operative risk.
Of the 578 identified patients, 233 (40%) were women. The women were older than the men at diagnosis (71 years vs 68 years; P = .006) but had had similar comorbidities, with the exception of lower rates of coronary artery disease (37% vs 47%; P = .04) and higher rates of chronic obstructive pulmonary disease (45% vs 36%; P = .008). The Society for Vascular Surgery clinical comorbidity score was similar between the sexes. Women were less likely to have undergone prior aortic surgery (32% vs 53%; P < .0001) but had had more extensive aneurysms (P = .007) with greater rates of prohibitive anatomic risk factors (open repair, 31% vs 17% [P = .01]; endovascular repair, 33% vs 28% [P = .32]). The metrics of frailty were higher for the women, including recent unintentional weight loss (11% vs 5%; P = .002), limited physical activity tolerance (46% vs 31%; P < .0001), and the need for ambulatory assistance (13% vs 6%; P < .0001). Of the 578 patients, 55% of the women and 30% of the men had had at least one frailty metric that was prohibitive for open repair (P = .0006). The women had also scored higher on the modified frailty index (P = .009). For open repair, 74% of women and 61% of men had at least one prohibitive risk factor. The women were also more likely to have multiple types of prohibitive risk factors. Compared with the men, the women were less likely to be offered repair (60% vs 74%; P = .0009) and less likely to undergo repair (44% vs 62%; P = .0001).
Women with TAAAs had increased metrics of frailty and anatomic risk that were not captured by comorbidity-based risk assessments. This suggests that frailty, together with complex anatomy, could explain the lower intervention rates for women with TAAAs.
胸主动脉腹主动脉瘤（TAAA）的手术修复风险较高，许多患者不适合介入治疗。先前的研究表明，女性接受修复的比例低于男性。造成这种差异的原因尚不清楚，但可能包括合并疾病负担较重或解剖学障碍。衰弱也可能导致干预率降低，但在术前风险评估中很少有报道。本研究旨在评估未经选择的 TAAA 患者队列中性别相关的临床合并症、解剖学适宜性和衰弱差异。
回顾了 2009 年至 2019 年期间在一家医疗机构接受计算机断层扫描成像证实的 I 至 V 型 TAAA 的所有患者。无论是否进行过修复，均纳入患者。收集临床合并症、解剖细节和衰弱指标，以确定手术风险。
在确定的 578 名患者中，有 233 名（40%）为女性。与男性相比，女性在诊断时年龄更大（71 岁比 68 岁；P =.006），但合并症相似，除了冠心病的发病率较低（37%比 47%；P =.04）和慢性阻塞性肺疾病的发病率较高（45%比 36%；P =.008）。血管外科学会临床合并症评分在性别之间相似。女性接受过先前的主动脉手术的比例较低（32%比 53%；P<.0001），但患有更广泛的动脉瘤（P=.007），具有更高比例的不可行解剖危险因素（开放修复，31%比 17%[P=.01]；血管内修复，33%比 28%[P=.32]）。女性的衰弱指标更高，包括最近非故意体重减轻（11%比 5%；P=.002）、体力活动耐量有限（46%比 31%；P<.0001）和需要助行器（13%比 6%；P<.0001）。在 578 名患者中，55%的女性和 30%的男性至少有一项衰弱指标不适合开放修复（P=.0006）。女性的改良衰弱指数评分也更高（P=.009）。对于开放修复，74%的女性和 61%的男性至少有一个不可行的风险因素。女性也更有可能有多种类型的不可行风险因素。与男性相比，女性接受修复的可能性较低（60%比 74%；P=.0009），接受修复的可能性也较低（44%比 62%；P=.0001）。
患有 TAAA 的女性衰弱和解剖学风险的指标更高，这些指标无法通过基于合并症的风险评估来捕捉。这表明，衰弱和复杂的解剖结构可能解释了 TAAA 女性干预率较低的原因。
