Regarding "Effect of gender on long-term survival after abdominal aortic aneurysm repair based on results from the Medicare national database" Reply

Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter (Impact Factor: 2.98). 04/2011; 54(1):1-12.e6; discussion 11-2. DOI: 10.1016/j.jvs.2010.12.049
Source: PubMed

ABSTRACT Historically, women have higher procedurally related mortality rates than men for abdominal aortic aneurysm (AAA) repair. Although endovascular aneurysm repair (EVAR) has improved these rates for men and women, effects of gender on long-term survival with different types of AAA repair, such as EVAR vs open aneurysm repair (OAR), need further investigation. To address this issue, we analyzed survival in matched cohorts who received EVAR or OAR for both elective (eAAA) and ruptured AAA (rAAA).
Using the Medicare Beneficiary Database (1995-2006), we compiled a cohort of patients who underwent OAR or EVAR for eAAA (n = 322,892) or rAAA (n = 48,865). Men and women were matched by propensity scores, accounting for baseline demographics, comorbid conditions, treating institution, and surgeon experience. Frailty models were used to compare long-term survival of the matched groups.
Perioperative mortality for eAAAs was significantly lower among EVAR vs OAR recipients for both men (1.84% vs 4.80%) and women (3.19% vs 6.37%, P < .0001). One difference, however, was that the survival benefit of EVAR was sustained for the 6 years of follow-up in women but disappeared in 2 years in men. Similarly, the survival benefit of men vs women after elective EVAR disappeared after 1.5 to 2 years. For rAAAs, 30-day mortality was significantly lower for EVAR recipients compared with OAR recipients, for both men (33.43% vs 43.70% P < .0001) and women (41.01% vs 48.28%, P = .0201). Six-year survival was significantly higher for men who received EVAR vs those who received OAR (P = .001). However, the survival benefit for women who received EVAR compared with OAR disappeared in 6 months. Survival was also substantially higher for men than women after emergent EVAR (P = .0007).
Gender disparity is evident from long-term outcomes after AAA repair. In the case for rAAA, where the long-term outcome for women was significantly worse than for men, the less invasive EVAR treatment did not appear to benefit women to the same extent that it did for men. Although the long-term outcome after open repair for elective AAA was also worse for women, EVAR benefit for women was sustained longer than for men. These associations require further study to isolate specific risk factors that would be potential targets for improving AAA management.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Current practice guidelines recommend repair of asymptomatic abdominal aortic aneurysms once they reach the 5.5-cm-diameter threshold and are based on information from randomized controlled trials. However, because aneurysms are more common in men, women are under-represented in these trials, and questions persist about whether this repair threshold should apply to them. In addition, women have smaller aortas to begin with and in most aneurysm cohorts are older, have more atherosclerotic risk factors, are less likely to be anatomic candidates for endovascular repair, and do poorer after emergency or elective repair of their aneurysm. These are just some of the issues that our discussants address in determining whether the repair threshold should be at a smaller diameter for women. Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
    European Journal of Vascular and Endovascular Surgery 12/2014; 60(6):1695-701. DOI:10.1016/j.jvs.2014.07.022 · 3.07 Impact Factor
  • European Journal of Vascular and Endovascular Surgery 12/2014; 48(6):614-8. DOI:10.1016/j.ejvs.2014.08.016 · 3.07 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective Factors affecting mortality after abdominal aortic aneurysm (AAA) repair have been extensively studied, but little is known about the effects of the shift to endovascular aneurysm repair (EVAR) vs open repair on failure to rescue (FTR). This study examines the impact of treatment modalities on FTR for elective AAA surgery during the years 1995 to 2011. Methods Data for 491,779 patients undergoing elective AAA surgery were collected from Medicare files. Patient demographics, comorbidities, hospital volume, and repair type were collected. Primary outcome was FTR: the percentage of deaths in patients who had a complication within 30 days of surgery. Data were analyzed by univariate and multivariate analysis. Results Patients undergoing AAA surgery have become progressively more complex, with 84.96%, 89.33%, 93.76%, and 95.72% presenting with one or more comorbidities in 1995, 2000, 2005, and 2011, respectively. Despite this, overall FTR after AAA surgery was stable from 1995 to 2000 (P = .38) and decreased from 2.68% to 1.58% between 2000 and 2011 (P < .001). In addition, FTR in EVAR decreased from 1.70% to 0.58% from 2000 to 2006 (P = .03) and then stabilized at 0.88% ± 0.9% after 2007 (P = .45). Unlike for EVAR, FTR for open repair remained stable at 3.06% ± 0.17% to 2.74% ± 0.16% from 1995 to 2000 (P = .38) but increased to 4.51% ± 0.21% in 2011 (P < .001). Mortality was highest after transfusion (20.86%), prolonged ventilation (17.37%), and respiratory complications (29.78%) for all AAA surgeries. Of note, high-volume hospitals had lower FTR rates than low-volume hospitals for both open (2.73% vs 5.66%; P < .001) and endovascular (0.7% vs 1.69%; P < .001) repair. Multivariate analysis showed that high annual volume hospital status (odds ratio, 0.6; confidence interval, 0.58-0.63) and endovascular repair (odds ratio, 0.3; confidence interval, 0.28-0.31) were associated with decreased FTR. Conclusions The success in AAA surgery of rescuing patients from 30-day mortality after a complication is associated with increased volume of EVAR. This increased success can also be attributed to the improved FTR outcomes and complication rates when surgeries are performed at high-volume hospital centers.
    Journal of Vascular Surgery 12/2014; DOI:10.1016/j.jvs.2014.08.106 · 2.98 Impact Factor

Full-text (2 Sources)

Available from
Jun 1, 2014