Even With EVAR, Women With AAA Face Starkly Different Survival Than Men

Women diagnosed with an abdominal aortic aneurysm (AAA) are less likely to be deemed eligible for endovascular repair, less likely to undergo intervention, and less likely to survive if they get it, a new study suggests.

“The management of abdominal aortic aneurysm in women needs improvement,” the authors say bluntly.

The higher mortality among women with AAA has been previously observed among patients undergoing open surgical repair, senior author Janet Powell, MD (Imperial College London, England), told TCTMD. The current paper, however, represents the largest analysis comparing outcomes in men and women undergoing endovascular repair (EVAR) or surgery, she said. “And this is the first good demonstration that the difference in outcomes with EVAR [between men and women] are exactly the same.”

The meta-analysis, with first author Pinar Ulug, PhD (Imperial College London, England), was published April 25, 2017, in the Lancet.

Ulug and colleagues conducted a literature review to identify studies that included information on morphological eligibility for EVAR, the patients offered EVAR or open repair, and 30-day mortality. The aim was to pinpoint the stage at which disparities between men and women start emerge.

Of five studies that reported morphological eligibility for EVAR, more than half of the men evaluated were deemed eligible for EVAR as compared with just a third of the women (54% vs 34%, OR 0.44; 95% CI 0.32-0.62). Of the four papers that reported intervention rates—both EVAR or surgery—a full third (34%) of women eligible for intervention did not undergo treatment, either because they were not offered it or they refused. In men, that portion was just 19% (OR 2.27; 91% CI 1.21-4.23).

Finally, among nine papers that reported mortality among patients offered elective repair, women in the pooled estimate were significantly more likely to die than men following EVAR (2.3% vs 1.4%, OR 1.67; 95% CI 1.38-2.04) as well as following surgery (5.4% vs 2.8%, OR 1.76; 95% CI 1.35-2.30).

“Compared with men, a smaller proportion of women are eligible for EVAR, a higher proportion of women are not offered intervention, and operative mortality is much higher in women for both EVAR and open repair,” Ulug and colleagues conclude.

Disadvantaged, Every Step of the Way

The current study is part of a larger project geared dubbed the SWAN (Screening Women for Aortic Aneurysm) collaboration, which aims to establish how best to decide when or if to screen for AAA in women as well as when or if to intervene, Powell explained.

Women tend to develop AAA at an older age, she noted. “So should women come in sooner? Should we change the definition of an aneurysm in women because they have smaller arteries? Should we intervene at smaller diameters, because at smaller diameters their aorta is more likely to be more suitable for the endovascular approach?” All of these questions need answers, she said.

Beyond that, Powell continued, “can we try and get some interaction with the companies that produce the endografts, to have them design endografts for women rather than use grafts that are essentially designed for men?” All of these are things “that need to be tested and examined,” she stressed.

The higher mortality seen even among women undergoing EVAR should also be an eye-opener for the field, the authors suggest. “It would seem to be crucial either to design an endograft for women or to accept that most women need to be referred to centers that either offer endovascular sealing technology or are specialists in open repair,” they write.

For Powell, the most striking finding of their meta-analysis is that discrepancies between men and women were not isolated to a single point of care. “It’s at every single step of this care pathway that women are disadvantaged,” she said. “We know that there are standard procedures in the operating room, even down to how much fluid they should get. And perhaps, especially in older women, this shouldn’t be the same for men and women. I do think this issue of reporting things for women and for men separately is quite important, because they may react to various insults in a different manner.”