Post-EVAR Survival for Women on Par with Men



MILWAUKEE – Although female gender is associated with a higher rate of complications, women did not have significantly lower long-term survival after endovascular abdominal aortic aneurysm repair in a review of the Mayo Clinic AAA Registry.

At 30 days, 24% of women experienced complications after EVAR, compared with 15% of men (P value = .003).

Patrice Wendling/IMNG Medical Media

Dr. Peter Gloviczki

On the other hand, death at 30 days was similar (2.5% vs. 1.5%; P = .41), as was combined early or late death (hazard ratio 1.1 vs. 1.0; P = .36), Dr. Peter Gloviczki reported at the meeting.

He highlighted a recent prospective analysis from Albany (N.Y.) Medical College showing that women had significantly higher mortality than did men (3.2% vs. 0.96%, P less than .005) and more frequent colon ischemia, native arterial rupture, and type 1 endoleaks after elective EVAR. There were no gender differences, however, for any of these outcomes following elective open repair or emergency EVAR or surgery (Vasc. Surg. 2012;55:906-13. Epub 2012 Feb. 8).

In the Mayo Clinic analysis, urgent presentation, age over 70 years, and high comorbidity scores were all significantly associated with complications and higher mortality, said Dr. Gloviczki, president of the Society for Vascular Surgery (SVS) and chair emeritus vascular and endovascular surgery, Mayo Clinic, Rochester, Minn.

The retrospective analysis included 1,002 consecutive patients with abdominal aortic aneurysm (AAA) treated with EVAR at Mayo Clinic from January 1997 to June 30, 2011. Of these, 871 were male (87%) and 131 female (13%). The majority (919) of cases were elective (92%), 43 symptomatic (4%), and 40 ruptured AAA (4%). Patients’ average age was 76 years (range 51-99 years).

Thirty-day mortality was 1% in the elective group, compared with 2.3% in the symptomatic AAA group and 12.5% in the ruptured AAA group (both P less than .0001), he said.

In contrast to the Albany analysis, early mortality after elective repair was similar between men and women (0.75% vs. 2.61%; P = .09). This was further confirmed by multivariate analysis (hazard ratio for all-cause death 1.16; P = .40), despite an increased risk in women for complications (HR 1.67; P = .001) and reinterventions (HR 1.96; P = .002), Dr. Gloviczki said.

High-risk patients, defined by an SVS comorbidity score of more than 10, however, had significantly higher 30-day mortality after elective EVAR than did low-risk patients (2.33% vs. 0.18%; P = .004).

This was driven by a significantly higher rate of early complications in the high-risk group (19.3% vs. 11.4%), particularly myocardial infarction (1.6% vs. 0.18%) and acute renal failure requiring temporary dialysis (3.26% vs. 1.09%; P less than .05 for all), Dr. Gloviczki observed.

At an average follow-up of 3.2 years, overall survival was significantly higher in patients undergoing elective EVAR vs. symptomatic or ruptured repair (64% vs. 50% and 56%; P less than .001), and in low-risk vs. high-risk elective patients (72% vs. 51%; P less than .001).

Both 30-day mortality and complications significantly increased with age after elective repair, he said.

Overall, there were five late ruptures and nine late conversions, for a complication-free 5-year survival of 64% in the elective group.

Dr. Gloviczki noted that access-related difficulties are driving the higher early complication rate in women, but that other factors like age and comorbidities may be at play.

He noted that Mayo Clinic performed its first EVAR in 1996, and that today, 63% of patients with an aneurysm undergo endovascular repair.

When asked what’s changed in his patient selection and aneurysm size cutoff, Dr. Gloviczki said that in younger patients, surgeons may want to intervene earlier if the aneurysm appears likely to increase in size and is suitable for an endograft, but that overall, age alone should not drive patient selection.

"What this study showed me is that characterizing patients as high risk vs. low risk is important, in addition to age," he said. "As you could see, there was an increased mortality in age, but when we looked at high-risk and low-risk criteria, we only lost one patient in the low-risk group. So age alone does not put you into a high-risk category, it is your additional cardiac, pulmonary and renal disease that does."

Dr. Gloviczki and his coauthors reported no relevant conflicts of interest.

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