J Thorac Cardiovasc Surg 2004;127:325-328
© 2004 The American Association for Thoracic Surgery
a Division of TCV Surgery, University of Virginia Health System, Charlottesville, Va, USA
b Division of Vascular Surgery, University of Maryland, Baltimore, Md, USA
c Department of Vascular Surgery, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
d Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md, USA
e Section of Vascular Surgery, Yale University School of Medicine, New Haven, Conn, USA
Received for publication September 29, 2003; accepted for publication October 6, 2003.
* Address for reprints: Vivian Gahtan, MD, SUNY Upstate Medical University College of Medicine, Department of Surgery, 750 East Adams St, Syracuse, NY 13210 , USA
The prevalence of abdominal aortic aneurysms (AAAs) has been reported to be higher in men than in women. Most prevalence studies (AAA diagnosed by means of autopsy, ultrasound screening, and hospital discharge data) demonstrated the percentage of AAAs diagnosed in women to be 19% to 34% and the percentage diagnosed in men to be 66% to 81%.1-5 This rate appears to be reliably constant in many Western nations. No cause or causes for the dramatic difference in the prevalence of AAAs between the sexes has been identified.
Risk-factor profiles appear to be similar for both sexes. Age, cigarette smoking, and family history are all reported to have high association with AAA formation.5,6 Women are usually older than their male counterparts when they undergo AAA repair (Tables 1 and 2). 1,6-12 Men have a higher association of ischemic coronary artery disease and peripheral aneurysms (usually femoral or popliteal in location), and women have a higher incidence of concomitant aortoiliac occlusive disease.6
Several studies that examined hospital data (prevalence of AAAs and subsequent surgical treatment) suggested that women are offered surgical repair of AAAs at an alarmingly lower rate than their male counterparts.7,10,11 Unfortunately, these studies could not provide further data regarding the decision not to repair the AAA. Perhaps the women decided to forego therapy. Also possible is that their aneurysms were smaller than those of their male counterparts, making risk of rupture less likely and surgical repair less beneficial on the basis of the assumptions of size and rupture risk for men. Most studies demonstrated that women with AAAs are significantly older than men with AAAs when undergoing repair (Tables 1 and 2).6-9,12 Women might become older while the treatment team waits for the aneurysm to reach an absolute size before considering repair. Increased age might also dissuade either the patient or treating physician from pursuing aneurysmectomy because advanced age has been shown in some studies to portend a worse outcome.1,8,9,12
In-hospital mortality rates for elective AAA repair have been reported to be similar for men and women. A significant number of large, population-based reports have been published and are summarized in Table 1. These studies again demonstrate the large difference of prevalence of AAAs in men when compared with those in women. Most studies found no difference in perioperative mortality between men and women1,6,9,10; however, several studies did demonstrate statistically significant higher mortality in women.7,8,12
Perioperative mortality after repair of a ruptured AAA is summarized in Table 2. Fewer studies examined the outcomes of ruptured AAA than elective AAA. The data from these reports are contradictory in terms of higher mortality in women when compared with that in men while undergoing repair of a ruptured AAA. The women were significantly older than men who receive treatment for ruptured AAA. This difference is even greater than that reported for elective AAA repair. This fact might partially, or even fully, explain the difference in mortality because age is another independent risk factor for mortality.
Endovascular repair of AAA was first introduced in 1991.14 Large volumes of commercially produced devices became available in the United States in the mid-1990s. Two devices gained US Food and Drug Administration approval in 1999, one in 2002, and another in 2003. Several reports have been published that examine the differences between men and women who underwent endovascular repair. Unfortunately, some of these studies had extremely low numbers of women evaluated and treated. It is difficult to compare outcomes for all devices because these devices are designed in unique ways that might cause different outcomes on the basis of device or patient selection alone. In addition, several devices have had modifications over time, which also makes comparisons difficult. Reports of large series of endovascular AAA repair demonstrate 11% (1018 total patients)15 and 14% (703 total patients)16 of treated patients were women. This is an even lower rate than that reported in many open surgical series. Women might not be candidates for endovascular repair because of several anatomic features. These include small access vessels, which might make passage of these large devices complex or impossible, and short, wide, and angulated aortic necks, which might prevent successful exclusion of blood flow from into the aneurysm sac.17 Most series demonstrated that a significantly higher number of women were ineligible for endovascular repair because of anatomic concerns.17-19 Despite these issues, 2 reports demonstrated no significant difference in mortality or morbidity between men and women who underwent endovascular AAA exclusion.17,20 As the technologic aspects of endografts improve, which includes smaller device profiles and greater variability in neck sizes and attachment options, more women might become eligible for endograft placement.
AAA affects significantly fewer women than men in Western nations. Women receive diagnoses and are treated at a more advanced age than similarly affected men. Women might be offered surgical repair at a significantly lower rate than men. Whether women have greater mortalities after open AAA repair (both elective and emergency) remains unclear. Women have more challenging anatomies for endovascular AAA repair, thus frequently excluding them from this treatment modality.
Future challenges include 3 important issues.
This is a project of the Society of Vascular Surgery, Committee on Women's Issues.
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