Surgical treatment of abdominal aortic aneurysms: is there difference in the results between men and women?
(Portuguese PDF version)

Telmo Pedro Bonamigo,1 Márcio Luís Lucas,2 Nilon Erling Jr.3

1. Head of the Angiology and Vascular Surgery Service, Complexo Hospitalar Santa Casa de Porto Alegre, RS, Brazil. Associate Professor, Vascular Surgery, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA), Porto Alegre, RS, Brazil.
2. Physician, vascular surgeon. Former resident, Angiology and Vascular Surgery Service, Complexo Hospitalar Santa Casa de Porto Alegre, RS, Brazil.
3. Resident, Angiology and Vascular Surgery Service, Complexo Hospitalar Santa Casa de Porto Alegre, RS, Brazil.

Correspondence:
Telmo Pedro Bonamigo
Rua Coronel Bordini, 675/303
CEP 90440-002 - Porto Alegre, RS - Brazil
Tel./Fax: +55 (51) 3333.1642
E-mail: telmobonamigo@terra.com.br

ABSTRACT

Objective: To evaluate the perioperative results in patients submitted to elective conventional open repair of abdominal aortic aneurysm, comparing the results between women and men in relation to the perioperative mortality and morbidity, as well as long term outcomes.

Patients and methods: Between December 1983 and December 2003, 675 patients were submitted to infrarenal abdominal aortic aneurysm repair. We divided them into two groups: men (n = 575) and women (n = 100). Demographic and operative data, as well as perioperative outcomes were obtained from chart review. Discharged patients formed a retrospective cohort, in which the late death causes and survival were evaluated.

Results: The mean age was similar, but no statistical difference was observed between men and women (68.9± 9.1 versus. 67.4± 7.1 years; P = 0.089). The presence of hypertension was significantly higher in women (73 versus 62.4%; P = 0.042), and coronary artery disease and history of smoking were more prevalent in men (P < 0.05). The overall mortality rate was 2.8%, without any significant difference between women and men (4 versus 2.6%, respectively; P = 0.43). Perioperative morbidity was similar in both groups (14% for women; 18.4% for men; P > 0.05). The survival rates in 1, 3, 5, and 10 years were similar in the groups, with 5-year survival of 71% for women and 72% for men (P > 0.05). Cardiovascular disease was the main late death cause in both groups, followed by renal complications in women and neoplasia in men.

Conclusion: The perioperative mortality and morbidity rates did not significantly increase in women after the conventional infrarenal abdominal aortic aneurysm repair. Furthermore, the long term results are similar between both genders.

Key-words: Abdominal aortic aneurysm, surgery, women.

J Vasc Bras. 2006;5(2):101-8

Article submitted March 6, 2006, accepted June 6, 2006.

INTRODUCTION

It is well known that the outcome after clinical treatment of acute myocardial infarction and after coronary revascularization surgery is worse in women than in men.1,2 Nevertheless, some authors have been studying the influence of gender on the outcome after peripheral vascular surgery.3-6

The prevalence of abdominal aortic aneurysm (AAA) is higher in men than in women.7,8 Therefore, most studies have reported outcomes mainly in male patients.9

Some studies have demonstrated that female gender has a negative influence on the outcome after surgical treatment of AAA;3,10 however, other studies do not support such difference.11,12 Furthermore, few studies have evaluated the influence of gender on perioperative morbidity and on long-term outcomes after AAA surgery.

Therefore, our objective is to evaluate the influence of gender on surgical morbidity and mortality, as well as long-term outcomes in patients submitted to abdominal aortic aneurysmectomy.

PATIENTS AND METHODS

Between December 1983 and December 2003, 675 patients were submitted to AAA surgery by the first author (T.P.B.). Of these, 100 (14.8%) were female. All patients had unruptured infrarenal aortic aneurysm.

Besides history and clinical examination, preoperative diagnosis was performed, basically using ultrasonography and abdominal computed tomography. Aortography was performed in 122 patients (108 men), being indicated in case of suspicion of aortoiliac/femoral occlusive disease, renovascular or visceral occlusive disease, and involvement of renal arteries by the aneurysm. There was no increase in surgical morbidity in the patients submitted to the examination. Surgical procedure was carried out using conventional technique through transperitoneal approach to the abdominal aorta with an incision from xiphoid to pubis. The patients remained at the intensive care unit during the first 24 hours, and additional hospitalization time was indicated due to clinical events or complications.

In-hospital or 30-day morbidity and mortality rates were evaluated. Moreover, surgical aspects such as time of procedure, time of aortic clamping and blood loss during surgery were also evaluated. Average aneurysm diameter, involvement of iliac arteries by the aneurysmal disease, and presence of inflammatory type were also studied.

The patients with hospital discharge were followed through a program of clinical follow-up, which was carried out in follow-up visits, questionnaires sent by mail or telephone interviews. Such strategy allowed us to know the patients' survival rates, as well as the causes of death during late postoperative episode.

Data were expressed in absolute or relative values (percentage), and mean and standard deviation were calculated whenever necessary. Statistical analysis was carried out using the chi-square test (Χ2), Fisher's exact test or Student's t test whenever indicated. Analysis of survival was performed using the Kaplan-Meier curve and the log-rank test. P < 0.05 was considered significant.

RESULTS

Patients' clinical and demographic characteristics are presented in Table 1. Mean age in women was similar to men's (68.9 ± 9.1 versus 67.4 ± 7.2 years; P = 0.089). With regard to comorbidities, hypertension was significantly higher in women (73 versus 62.4%; P = 0.042), whereas history of smoking and coronary artery disease and were more prevalent in men (P < 0.05). There was no statistically significant difference with regard to the presence of cerebrovascular disease, chronic renal insufficiency, and diabetes mellitus.

click hereTable 1 - Demographic data and comorbidities

Characteristics Women (n = 100) Men (n = 575) P
Mean age (years) 68.9 ± 9.1 67.4 ± 7.2 0.089
Arterial hypertension 73 (73%) 359 (62.4%) 0.042
Smoking 45 (45%) 412 (71.6%) 0.00...
Coronary artery disease 14 (14%) 131 (22.8%) 0.048
Diabetes mellitus 6 (6%) 36 (6.3%) 0.95
CRF (creatinine ≥ 2.0) 4 (5.1%)* 31 (7.2)* 0.49
Previous TIA/stroke 3 (3%) 16 (2.8%) 0.98
* Total of 78 and 430 patients, respectively; CRF = chronic renal failure (serum creatinine values higher than 2 mg/dl); TIA = transient ischemic attack.

With regard to aneurysm characteristics, mean diameter in women was significantly lower than in men, which is probably related to lower height in women (5.94 ± 1.5 versus 6.57 ± 2.25 cm; P = 0.005). Involvement of iliac arteries by the aneurysmal disease did not differ between men and women (15 versus 9%; P > 0.05), and the presence of inflammatory aneurysm was seen in seven women (7%) and 30 men (5.2%) (P = 0.47) (Table 2).

click hereTable 2 - Surgical characteristics

Characteristics Women (n = 100) Men (n = 575) P
Duration of surgery (min) 205.1 ± 57.6 203.7 ± 57.7 0.676
Aortic clamping (min) 45.9 ± 16.5 47.5 ± 16.7 0.349
Blood loss (ml) 996.3 ± 712.4 1,026 ± 624.8 0.83
Mean AAA diameter (cm) 5.94 ± 1.5 6.57 ± 2.25 0.005
Iliac artery aneurysm 9 (9%) 85 (15%) 0.12
Inflammatory type 7 (7%) 30 (5.2%) 0.47
AAA = abdominal aortic aneurysms.

Mean surgical time was 205.1 (± 57.6) min for women and 203.7 (± 57.7) min for men (P = 0.676). Aortic clamping time (45.9 ± 16.5 versus 47.5 ± 16.7 min) and blood loss during surgery (996.3 ± 712.4 versus 1,026 ± 624.8 ml) were not different between women and men, respectively (P > 0.05) (Table 2).

Overall perioperative mortality rate was 2.8%: 4% in women and 2.6% in men (P = 0.43). Surgical morbidity affected 14% of female patients and 18.4% of male patients (P = 0.28) (Table 3). The main causes of death in both genders were due to coronary artery disease. There was no difference in perioperative complications; cardiopulmonary and gastrointestinal events were the most common for both groups (Table 3).

click hereTable 3 - Perioperative morbidity and mortality and its causes

Women (n = 100) Men (n = 575) P
Mortality 4 (4%) 15 (2.6%) 0.43
  Coronary artery disease 2 5
  Multiple organ failure 1 2
  Mesenteric thrombosis 1 2
  Pulmonary embolism - 1
  Stroke - 2
  Sepsis/infection - 3
Morbidity 14 (14%) 106 (18.4%) 0.28
  Coronary 5 (5) 34 (5.9)  
  Pulmonary 6 (6) 31 (5.3)
  Renal 2 (2) 6 (1)
  Gastrointestinal 6 (6) 26 (4.4)
  Infectious 2 (2) 14 (2.4)
  Vascular 2 (2) 16 (2.7)

 

The patients with hospital discharge (n = 656) formed a retrospective cohort in this study. During clinical follow-up, 38 patients (5.8%) were lost: 32 men and 6 women. Survival rate in 1, 3, 5 and 10 years was 89, 82, 71 and 52% for women and 87, 82, 72 and 56% for men, respectively. According to the analysis of the survival curve, there was no statistically significant difference between the rates obtained in both groups (Figure 1). The causes of late death during the patients' clinical follow-up are listed in Table 4. During the follow-up by variable periods, 34 women (37.8%) and 228 men (43.2%) died. In 10 patients (3.8%), all of them male, the cause of death could not be identified. Among the known causes, 55.9% of women and 47.2% of men died of cardiovascular diseases. In women, the most relevant cause of late death was renal failure. In men, there was prevalence of neoplasias and chronic respiratory diseases.

click hereFigure 1 - Ischemic ulcer

click hereTable 4 - Causes of late death in patients submitted to AAA surgery

Causes Women Men
Number of patients 100 575
Perioperative deaths 4 (4%) 15 (2.6%)
Patients with hospital discharge 96 560
Patients "lost" during follow-up 6 (6.25%) 32 (5.7%)
Patients with follow-up 90 528
Follow-up median 66 months 65 months
Deaths during follow-up 34 (%) 228 (%)
Known causes of death
  Cardiovascular 19 (55.9%) 103 (47.2%)
  Respiratory 2 (5.9%) 30 (13.8%)
  Neoplastic 2 (5.9%) 39 (17.9%)
  Renal 4 (11.8%) 9 (4.1%)
  Infectious 0 (0) 7 (3.2%)
  Others 7 (20.6%) 30 (13.8%)
Unknown causes 0 (0) 10 (4.4%)

DISCUSION

The main risk factors for AAA are: male gender, age over 65 years, and history of smoking.13 Other associated factors are: family history, coronary artery disease, hypertension, cerebrovascular disease, and being tall. Diabetic and black women have reduced risk for AAA development.13

Knowing the differentiated outcomes of AAA surgery between men and women is important, since it provides guidance for therapeutic and screening strategies. Since most patients were men, there might have been a generalization of results.4 Female gender represents up to 20% of patients submitted to AAA surgery. Elective and emergency AAA surgery may be three to five times more frequent in men.5

In screening studies, the prevalence of AAA ranges from 4 to 9% in men and up to 1% in women.13 In our country, such prevalence is near 7% in cardiac patients with previous myocardial revascularization.14 The Aneurysm Detection and Management (ADAM) study revealed a 1.3% prevalence of AAA in women.9 Due to such a low frequency of AAA in women, screening programs are not justified for this population, since the number of AAA-related deaths that can be prevented in this group is low.13 The Society of Vascular Surgery and the Society for Vascular Medicine and Biology recommend AAA screening in men and women aged 60-85 years with cardiovascular risk factors and for men and women older than 50 years with family history of AAA.15 According to the ADAM study, family history of AAA and presence of cerebrovascular disease were more frequent in women.9

The influence of gender on the outcome after peripheral vascular surgery has been studied in previous trials. With regard to carotid artery disease, its prevalence is lower in women than in men, with a 3:2 to 8:1 ratio,6 and procedures in the carotid artery of female patients range from 27 to 42%.16,17 Concerning postoperative outcomes, most studies indicate worse outcome in women, with higher stroke rate.18,19

With regard to infrainguinal revascularization surgeries, about 1/3 of procedures are performed in women, with perioperative mortality rates and medium- and long-term graft patency significantly lower in male patients.20,21

The cause for worse outcomes obtained in women after AAA surgery is unknown. It is assumed that there may be more comorbid diseases in this group of patients. In this context, a study including 582 patients (92 women) did not show difference in risk factors;22 however, a population study, with 5,419 patients, demonstrated that women had more cardiovascular comorbidities than men.6 Another cause could be the use of diameters similar to the AAA for surgical conduct and indication in both genders. This would allow later surgical indication in women, since their aortas have a smaller diameter. The ideal would be to consider the surgical treatment for AAA differently for both groups, as concluded by the UK Small Aneurysm Trial, in which surgery would be indicated for AAA with dimensions over 4.5 cm in women and 5.5 cm in men.23

With regard to the outcomes seen in our study, we verified that women had mean age a little higher than men and demonstrated a higher frequency of hypertension and smaller aneurysms. These findings are similar to those obtained by other authors.3,5,24-26 Nevertheless, some authors did not find a statistically significant difference in comorbid diseases between both genders.9,22

Few studies report the differences in perioperative mortality between genders after AAA repair. Our results did not show statistically significant difference in surgical morbidity between genders, being similar to the data obtained in Johnston's study.3 With regard to perioperative mortality, death occurred in 4% of women and 2.6% of men; there was no significant difference, in accordance with the results found by other authors.3,10,22 However, other studies have demonstrated a greater risk of death in women. Therefore, Katz et al., based on data obtained from more than 8,000 patients operated in Michigan, USA, between 1980 and 1990, have demonstrated a higher mortality rate in women.11 Similarly, by analyzing the results of the American Nationwide Inpatient Sample, Dimick et al. obtained a significantly higher mortality rate in women (5.3 versus 3.2%). Furthermore, these authors have also demonstrated that the worst outcomes were obtained in female patients, aged 65 years or more, and operated in low-volume hospitals (7.1%); the best outcomes were obtained in male patients, aged 65 years or less and operated in high-volume hospitals (0.8%).12

Norman et al.27 reviewed studies on outcomes after AAA surgery, comprising more than 10,500 patients, with mortality rate ranging from 0 to 10.4% and an average of 70% long-term survival rate in 5 years, compared with 80% in the general population. Only three studies have reported the comparison of long-term survival between men and women. None of these studies found a significant difference in 5-year survival between genders, ranging from 61 to 79% in women and from 63 to 79% in men.10,28,29 The Canadian study by Johnston did not show significant difference in 5-year survival between men (82.8%) and women (74.2%).3 Our results are in accordance with these findings, since survival rates in female patients (71%) are similar to those obtained for male patients (72%) (Table 5). Nonetheless, Norman et al.10 obtained worse long-term outcomes in female patients, compared with male patients, when the relative 5-year survival rate was analyzed (which is considered the most reliable form of long-term outcomes, since it is a comparison with the general population of the same age, gender and location). Stenbeak et al.4 obtained similar findings, in which the 5-year survival rate was similar in both genders; however, relative survival was worse in women. In our patients, the main cause of late death in both genders was due to cardiovascular disease, followed by neoplastic diseases, mainly in men, which is in accordance with the review carried out by Norman et al.27

click hereTable 5 - Long-term outcomes of elective AAA treatment in men and women

Year Study Period Cases Perioperative death 5-year survival
M F
1981 Crawford28 1955-80 737 M + 123 F 4.8% 63% 61%
1994 Johnston3 - 545 M + 134 F 4.4% M; 5.2% F 82.8% 74.2%
1995 Soisalon-Soininen29 1970-92 595 M + 111 F 7,4% 70% 72%
1998 Norman10 1985-94 796 M + 139 F 4.4% M; 3.6% F 79% 79%
2005 Bonamigo 1983-2003 575 M + 100 F 2.8% M; 4% F 71% 72%
F = female; M = male.

Although it is not an issue of our study, the influence of gender on outcomes after ruptured AAA surgery has also been studied by other authors. Evans et al.,30 based on a surgical audit database from England, analyzed almost 700 patients submitted to ruptured AAA surgery between 1983 and 1995. They did not find difference in perioperative mortality and long-term survival between both genders. In Johnston's study, mortality was 55% in men and 49.2% in women.3 Absence of difference in mortality after ruptured AAA repair was also obtained by other authors.31,32 On the other hand, some authors have demonstrated difference between genders on outcome after ruptured AAA surgery. Semmens et al.,33 for example, identified a 76% mortality rate for men and 90% for women (P < 0.0001). Similar results were also obtained by Johansen et al.34 (67 versus 90%). In a recent study by Dueck et al.,35 female gender was not deemed an independent factor for worse outcome in electively operated patients; however, in patients after ruptured AAA surgery, female gender proved to be an independent factor for worse perioperative outcome.

With regard to endovascular treatment, Ouriel et al.36 demonstrated similar results between men and women after AAA treatment, with perioperative mortality rate of 1.3 and 3.1%, respectively. These findings are in accordance with those obtained by Mathison et al.,26 who found a 2.8% mortality rate for men and 0.8% for women (P > 0.05), but with a higher success rate in the procedure in men and a higher percentage of aborted procedures in women. In the study by Sampaio et al.,24 there was no difference in perioperative mortality, survival and incidence of medium-term endoleak.

In short, we observed that prevalence of elective surgery for AAA was almost six times more common in men. Nevertheless, perioperative morbidity and mortality rates were similar across genders, despite women presenting hypertension more frequently and having smaller aneurysms than men, as well as men being cardiac patients and smokers more frequently. Furthermore, long-term survival outcomes did not differ across genders, with about half of late deaths occurring due to cardiovascular disease in both groups. Therefore, knowing the surgical outcome in patients from both genders allows a better decision regarding the conduct for patients with AAA.

 

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