title: Female sex independently predicts mortality after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms.
abstract: Whereas sex differences in the pathogenesis, presentation, and outcomes of repair for abdominal aortic aneurysms are well studied, less is known about sex differences after thoracic endovascular aortic repair (TEVAR). The goal of this study was to evaluate the association between sex and morbidity and mortality after TEVAR.
  
  
  
  A retrospective review of all TEVARs in the Society for Vascular Surgery Vascular Quality Initiative (VQI) registry from 2011 to 2015 was conducted, excluding those with dissection, trauma, and rupture. Statistical analysis was performed using the Fisher exact test and the Mann-Whitney U test for categorical and continuous variables. Multivariable logistic regression and Cox hazards modeling were used to account for differences in demographics, comorbidities, and aneurysm characteristics in 30-day mortality and long-term survival.
  
  
  
  We identified 2574 patients (40% women) who underwent TEVAR. Women were older, were less likely to be white, and had smaller aortic diameters but larger aortic size indices (aortic diameter/body surface area). Women also had more chronic obstructive pulmonary disease but less coronary artery disease and fewer coronary interventions. Women were more likely to be symptomatic at presentation and subsequently to have a nonelective procedure. Women had higher estimated blood loss >500 mL (20% vs 17%; P = .04), were more likely to be transfused (29% vs 21%; P < .001), and more frequently underwent iliac access procedures (4.3% vs 2.1%; P < .01). Operative time and left subclavian intervention were similar. Postoperatively, women had increased median hospital (5 vs 4 days; P < .001) and intensive care unit (2.5 vs 2 days; P < .001) lengths of stay and were less likely to be discharged home (75% vs 86%; P < .001). Mortality was higher for women at 30 days (5.4% vs 3.3%; P < .01) and 1 year (9.8% vs 6.3%; P < .01). After adjusting for age, aortic size index, symptoms, and comorbidities, female sex remained independently predictive of 30-day mortality (odds ratio, 1.5; 95% confidence interval, 1.1-2.1, P < .01) and long-term mortality (hazard ratio, 1.3; 95% confidence interval, 1.03-1.6; P = .02).
  
  
  
  Even after adjusting for differences in age and comorbidities, female patients have higher perioperative mortality and lower long-term survival after TEVAR. These findings, along with the rupture risk by sex, should be considered by clinicians in determining the timing of intervention.
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Deery
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Katie E
authors.initials: KE
authors.lastname: Shean
authors.affiliation: Division of Vascular and Endovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Grace J
authors.initials: GJ
authors.lastname: Wang
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, Va.
authors.forename: Gilbert R
authors.initials: GR
authors.lastname: Upchurch
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
authors.forename: Kristina A
authors.initials: KA
authors.lastname: Giles
authors.affiliation: Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Virendra I
authors.initials: VI
authors.lastname: Patel
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000367:Age Factors; D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality*; D015897:Comorbidity; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology