目的:基于性别的手术结果差异已成为当代医疗保健服务的重要焦点。同样,在美国,腹主动脉瘤腔内修复术(EVAR)的适当使用仍然是一个持续争议的主题,相当数量的美国EVAR未能遵守血管外科学会(SVS)临床实践指南(CPG)直径阈值。本研究的目的是确定不符合SVSCPG的EVAR患者的性别影响。
方法:分析了在SVS血管质量倡议(2015-2019年;n=25,112)中无伴随髂动脉瘤(≥3.0cm)的腹主动脉瘤的所有选择性EVAR手术。SVSCPG非顺应性修复被定义为男性<5.5cm,女性<5.0cm。主要终点是30天死亡率。次要终点是全因死亡率,并发症,和重新干预。进行Logistic回归以控制外科医生和患者水平的因素。使用Kaplan-Meier方法确定从终点的自由度。
结果:9675例患者(38.5%)进行了非依从性EVAR。尽管男性接受此类手术的可能性明显更高(90%vs10%;赔率比[OR],3.1;95%置信区间[CI],2.9-3.4;P<.0001),女性30天死亡率高于男性(1.8%vs0.5%;P=.0003).女性的多种并发症发生率也明显较高,包括术后心肌梗死(1%vs0.3%;P=.006),呼吸衰竭(1.4%vs0.6%;P=0.01),肠缺血(0.7%vs0.2%;P=0.003),进入血管血肿(3%vs1.2%;P=.0006),和髂动脉入路血管损伤(2.4%vs0.8%;P<0.0001)。此外,女性1年总再干预率增加(11.5%vs5.8%;P<0.0001).在调整后的分析中,30天死亡率和任何院内并发症的风险仍然显着增加妇女(30天死亡:OR,3.1;95%CI,1.6-5.8;P=.0005;院内并发症:OR,1.9;95%CI,1.4-2.6;P<0.0001)。与男性相比,随着时间的推移,女性的再干预率也有所增加(OR,1.5;95%CI,1.1-2.2;P=0.02)。
结论:尽管男性更有可能接受非CPG标准的EVAR,女性在接受非符合CPG标准的EVAR时,短期发病率和30日死亡率增加,再干预率较高.这些意想不到的发现需要加强对美国当前基于性别的EVAR实践的审查,并应警告女性不要使用非CPG标准的EVAR。
OBJECTIVE: Sex-based disparities in surgical outcomes have emerged as an important focus in contemporary healthcare delivery. Likewise, the appropriate usage of endovascular abdominal aortic aneurysm repair (EVAR) in the United States remains a subject of ongoing controversy, with a significant number of U.S. EVARs failing to adhere to the Society for Vascular Surgery (SVS) clinical practice guideline (CPG) diameter thresholds. The purpose of the present study was to determine the effect of sex among patients undergoing EVAR that was not compliant with the SVS CPGs.
METHODS: All elective EVAR procedures for abdominal aortic aneurysms without a concomitant iliac aneurysm (≥3.0 cm) in the SVS Vascular Quality Initiative were analyzed (2015-2019; n = 25,112). SVS CPG noncompliant repairs were defined as a size of <5.5 cm for men and <5.0 cm for women. The primary endpoint was 30-day mortality. The secondary endpoints were all-cause mortality, complications, and reintervention. Logistic regression was performed to control for surgeon- and patient-level factors. Freedom from the endpoints was determined using the Kaplan-Meier method.
RESULTS: Noncompliant EVAR was performed in 9675 patients (38.5%). Although men were significantly more likely to undergo such procedures (90% vs 10%; odds ratio [OR], 3.1; 95% confidence interval [CI], 2.9-3.4; P < .0001), the 30-day mortality was greater for the women than the men (1.8% vs 0.5%; P = .0003). Women also experienced significantly higher rates of multiple complications, including postoperative myocardial infarction (1% vs 0.3%; P = .006), respiratory failure (1.4% vs 0.6%; P = .01), intestinal ischemia (0.7% vs 0.2%; P = .003), access vessel hematoma (3% vs 1.2%; P = .0006), and iliac access vessel injury (2.4% vs 0.8%; P < .0001). Additionally, women experienced increased overall 1-year reintervention rates (11.5% vs 5.8%; P < .0001). In the adjusted analysis, 30-day mortality and any in-hospital complication risk remained significantly greater for the women (30-day death: OR, 3.1; 95% CI, 1.6-5.8; P = .0005; in-hospital complication: OR, 1.9; 95% CI, 1.4-2.6; P < .0001). Women also experienced increased reintervention rates over time compared with men (OR, 1.5; 95% CI, 1.1-2.2; P = .02).
CONCLUSIONS: Although men were more likely to undergo non-CPG compliant EVAR, women experienced increased short-term morbidity and 30-day mortality and higher rates of reintervention when undergoing non-CPG compliant EVAR. These unanticipated findings necessitate increased scrutiny of current U.S. sex-based EVAR practice and should caution against the use of non-CPG compliant EVAR for women.