Real-World TEVAR Population Shows Female Sex Independently Predictive of Mortality

Following thoracic endovascular aortic repair (TEVAR), women have worse short- and long-term mortality than men. The gender difference echoes similar observations that have been seen in patients undergoing both open and endovascular abdominal aortic aneurysm (AAA) procedures.

Researchers led by Sarah E. Deery, MD (Beth Israel Deaconess Medical Center, Boston, MA), say the reason is likely multifactorial but may be related to “more complicated aortic or access vessel anatomy, higher rates of symptomatic aneurysms, worse baseline health, and other social impacts on health status.”

The study, published in the July 2017 issue of the Journal of Vascular Surgery, was first presented last year at the Vascular Annual Meeting of the Society for Vascular Surgery.

Clear Mortality Differences

While data on disparities between men and women after AAA repair are abundant, they are decidedly less so for TEVAR, with some studies hinting at gender differences but none showing female sex to be an independent predictor of mortality.

“The sex differences we witnessed may be due to the fact that our cohort included patients with more medical and anatomic complexity than those seen in clinical trials, in which inclusion and exclusion criteria are stricter and procedures are limited to centers with demonstrated clinical expertise,” Deery and colleagues write.

The study of 2,574 patients (40% women) in the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry found that compared with men, women were more likely to be symptomatic at presentation, had higher estimated blood loss and more transfusions, had longer had hospital and intensive care stays, and were less likely to be discharged home.

Mortality at 30 days was 5.4% in women vs 3.3% in men (P < 0.01) and at 1 year was 9.8% vs 6.3%, respectively (P < 0.01). After adjusting for age, aortic size index, symptoms, and comorbidities, female sex remained independently predictive of both 30-day and 1-year mortality.

Thresholds May Come Into Play

“This [gender difference] is likely true because it has been seen in abdominal aortic aneurysm and the two procedures are not all that different,” said Frank A. Lederle, MD, of the Veterans Affairs Medical Center (Minneapolis, MN), in an interview with TCTMD.

But Lederle cautioned that in addition to uncertainty about completeness of information in registries such as this, there also are wide confidence intervals that would suggest the need to look more closely at the issue in larger datasets such as Medicare.

Deery et al note that different aneurysm size thresholds by sex have been suggested for AAA, given the higher rupture risk associated with smaller diameters in women. They add that more research is needed to “determine the ideal threshold for repair, by either diameter or aortic size index, weighing the reduced life expectancy and increased operative burden with the potential rupture risk.”

Lederle agreed, adding that the data “suggest that we should be doing less of these kinds of repairs in women, if we can. Certainly, regarding the aneurysms that are smaller than the threshold . . . it doesn’t make a lot of sense to be doing these procedures in women.”