J. E. Preiss1, R. K. Veeraswamy1, Y. Duwayri1, T. F. Dodson1, A. Salam1,2, S. Arya1, S. M. Shafii1, R. Rajani1, L. P. Brewster1,2 1Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 2VA Medical Center,Surgical And Research Services,Atlanta, GA, USA
Introduction: Abdominal aortic aneurysm (AAA) rupture carries high mortality risk and is the 10th leading cause of death in the United States. Elective aneurysm repair improves survival for patients with AAAs. Since female patients have a greater risk of rupture with smaller AAAs (<5.5 cm), many recommend elective repair prior to 5.5 cm. Endovascular aneurysm repair (EVAR) has significantly lower 30-day morbidity and mortality compared to traditional open repair, but these benefits disappear over time. In order to better assess the benefit of EVAR in female patients at our institution, the objective of this study is to identify if there are differences in late mortality between female patients undergoing elective EVAR for smaller AAAs compared to those who meet standard criteria.
Methods: Under IRB approval, we performed retrospective analysis of all patients that underwent EVAR for infrarenal AAA at our institution from June 2009 to June 2013. We excluded patients that were male, treated emergently or for iliac artery aneurysm, received renal or mesenteric artery stenting, and that died prior to 1-month follow-up. AAA measurements were obtained from 3D imaging reports. Females were considered to not meet anatomic criteria if preoperative AAA diameter was <5.5 cm or did not enlarge ≥0.5 cm in 6 months. Late mortality was assessed from the Social Security Death Index.
Results: 36 (22.2%) out of 162 elective EVAR patients were female. All 36 were eligible for 1-month follow-up with our institution (mean follow-up 37.2 months). 16 patients had AAA <5.5 cm without rapid growth while 20 patients had AAA ≥5.5 cm or with rapid growth. There were no differences in demographics or comorbidities between groups, although patients that did not meet criteria had smaller mean AAA diameter (5.02 cm vs. 5.83 cm, p=0.001). Despite no statistical difference in perioperative adverse events (Table 1), patients that did not meet traditional criteria had significantly higher late mortality (37.5% vs. 5%, p=0.02). After controlling for demographics and perioperative events, patients not meeting standard criteria still demonstrated increased risk of late mortality (OR 11.4, p=0.03). However when segregating patients only by AAA size (<5.5 cm vs. ≥5.5 cm), there was no statistical difference in late mortality (24% vs. 9.1%, p=0.30), and size did not influence odds of late mortality (OR 0.51, p=0.38).
Conclusion: There appears to be increased late mortality in female patients treated with EVAR at our institution for smaller and slower-growing AAAs. This late mortality may limit the benefit of EVAR for this population. Future work seeks to identify perioperative risk factors for late mortality that may be modified in postoperative care.
