Elsayed Nadin, Hamouda Mohammed, Rahgozar Shima, Ross Elsie, Schermerhorn Marc, Malas Mahmoud B
Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA.
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
Ann Vasc Surg. 2025 Jan;110(Pt A):286-293. doi: 10.1016/j.avsg.2024.08.020. Epub 2024 Oct 10.
Thoracic endovascular aortic repair (TEVAR) and complex endovascular thoraco-abdominal aneurysm repair have been increasingly adopted in the treatment of thoracic and thoracoabdominal aorta aneurysms, offering a less invasive approach for patients with appropriate anatomy. Women usually present with smaller aortic diameter. However, they usually have greater aneurysm growth rates. How sex can affect postoperative and short-term outcomes after TEVAR is not well reported. The aim of this study was to assess outcomes in female versus male patients undergoing TEVAR for treatment of thoracic and thoracoabdominal aneurysms in a Medicare-linked database.
We retrospectively reviewed patients undergoing TEVAR for thoracic and thoracoabdominal aneurysm repair in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018. Patients were divided into males and females. Patients presented with ruptured aneurysm were excluded from the analysis. Postoperative outcomes included in-hospital stroke, myocardial infarction, spinal cord ischemia, and 30-day mortality. One-year outcomes included mortality, aneurysmal rupture, and reintervention. Postoperative outcomes were assessed using multivariable logistic regression analysis and 1-year outcomes were evaluated using Kaplan-Meier Survival and Cox regression analyses.
A total of 3,058 males and 1,843 females were available for the analysis. Female patients had smaller median aortic diameter, were more likely to be Black, with chronic obstructive pulmonary disease, and chronic kidney disease, and to be symptomatic on presentation. Male patients were more likely to be on preoperative medications such as aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, P2Y12 antagonists, and anticoagulants. After adjusting for potential confounders, female gender was associated with double the risk of in-hospital stroke (odds ratio: 2.3, 95% confidence interval [CI] [1.5-3.7], P < 0.001) and 80% increase in 30-day mortality (odds ratio: 1.8, 95% CI [1.3-2.6], P = 0.001). At 1 year, female gender was associated with a higher risk of mortality (hazard ratio: 1.2, 95% CI [1.05-1.4], P = 0.011). There was a trend toward higher risk of reintervention (hazard ratio: 1.2, 95% CI [0.97-1.6], P = 0.079).
Mortality after TEVAR seems to be higher in female patients at 30 days and up to 1 year of follow-up. Female patients also face a 2 times higher risk of in-hospital stroke. Future studies with a larger female population should aim to identify and potentially ameliorate the factors associated with these unfavorable outcomes in females.
胸主动脉腔内修复术（TEVAR）和复杂的胸腹主动脉瘤腔内修复术在胸主动脉瘤和胸腹主动脉瘤的治疗中应用越来越广泛，为解剖结构合适的患者提供了一种侵入性较小的治疗方法。女性的主动脉直径通常较小。然而，她们的动脉瘤生长速度通常更快。性别如何影响TEVAR术后及短期预后的报道并不充分。本研究的目的是在一个与医疗保险相关的数据库中评估接受TEVAR治疗胸主动脉瘤和胸腹主动脉瘤的女性与男性患者的预后。
我们回顾性分析了2003年至2018年血管质量倡议血管植入监测和介入结果网络数据库中接受TEVAR治疗胸主动脉瘤和胸腹主动脉瘤修复的患者。患者分为男性和女性。分析排除了动脉瘤破裂的患者。术后结局包括院内卒中、心肌梗死、脊髓缺血和30天死亡率。1年结局包括死亡率、动脉瘤破裂和再次干预。术后结局采用多变量逻辑回归分析进行评估，1年结局采用Kaplan-Meier生存分析和Cox回归分析进行评估。
共有3058名男性和1843名女性可供分析。女性患者的主动脉直径中位数较小，更可能为黑人，患有慢性阻塞性肺疾病和慢性肾病，且就诊时出现症状。男性患者更可能术前使用阿司匹林、β受体阻滞剂、血管紧张素转换酶抑制剂、P2Y12拮抗剂和抗凝剂等药物。在调整潜在混杂因素后，女性发生院内卒中的风险增加一倍（比值比：2.3，95%置信区间[CI][1.5 - 3.7]，P < 0.001），30天死亡率增加80%（比值比：1.8，95%CI[1.3 - 2.6]，P = 0.001）。在1年时，女性的死亡风险更高（风险比：1.2，95%CI[1.05 - 1.4]，P = 0.011）。再次干预风险有升高趋势（风险比：1.2，95%CI[0.97 - 1.6]，P = 0.079）。
TEVAR术后30天及长达1年的随访中，女性患者的死亡率似乎更高。女性患者发生院内卒中的风险也高出2倍。未来针对更大女性群体的研究应旨在识别并可能改善与女性这些不良结局相关的因素。
