title: Women with abdominal aortic aneurysms have more extensive aortic neck pathology.
abstract: BACKGROUND
  The proportion of women with abdominal aortic aneurysm (AAA) treated with endovascular aortic repair (EVAR) is lower than for open repair (OR). Unfavorable morphologic features for EVAR in women with AAA may explain this disproportion. The objective of this study was to identify morphologic features in AAA patients undergoing elective repair with special emphasis on gender differences.
  
  
  METHODS
  Patients undergoing elective repair from January 1, 2006 to December 31, 2008 at our university's vascular unit were included in this study. Computed tomography (CT) angiograms were analyzed. Morphologic features considered unfavorable for EVAR rather than open repair (OR) included: infrarenal aortic neck <15 mm; angulation >60°; circumferential neck thrombus; neck width >32 mm; iliac arteries <7.5 mm; or presence of bi-iliac aneurysms. Complex aortic neck was defined as a neck length of <15 mm and one or more of the other aortic neck exclusion criteria.
  
  
  RESULTS
  One hundred seventy-two patients, including 140 men and 32 women, were treated during the study period, which included 99 with OR (21 women, 78 men) and 73 with EVAR (11 women, 62 men). Morphologic unsuitability for EVAR was 44% (75 of 172) and was not statistically different between women and men [47% (15 of 32) vs. 43% (60 of 140), P = 0.70]. Aortic neck pathology was the dominating feature for unsuitability for EVAR (69 of 75, 92%), and 85 of 172 patients had an unsuitable aortic neck. This rate was not different between women and men [19 of 32 (59%) vs. 66 of 140 (47%), P = 0.24]. Iliac unsuitability rates were 11% (19 of 172) and were not different between women and men [4 of 32 (12%) vs. 15 of 140 (11%), P = 0.76]. In patients unsuitable for EVAR, the proximal aortic necks showed more extensive aortic neck pathology in women than in men [8 of 15 (53%) vs. 13 of 60 (22%), P = 0.02]. More men had only short neck pathology [22 of 60 (37%) vs. 1 of 15 (7%), P = 0.03].
  
  
  CONCLUSIONS
  Aortic neck pathology is the dominating cause of EVAR exclusion in both genders. A higher proportion of women have more pathologic neck anatomy. Future development of EVAR devices should focus on the complexity of the aortic neck, which will benefit all AAA patients, but especially women.
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. Rebecka.hultgren@karolinska.se
authors.forename: Rebecka
authors.initials: R
authors.lastname: Hultgren
authors.forename: Liya
authors.initials: L
authors.lastname: Vishnevskaya
authors.forename: Carl Magnus
authors.initials: CM
authors.lastname: Wahlgren
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000473:pathology*; D017544:Aortic Aneurysm, Abdominal / Q000473:pathology* / Q000601:surgery; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged