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MILWAUKEE – Although female sex is associated with a higher rate of complications, women did not have significantly lower long-term survival after endovascular abdominal aortic aneurysm repair in a review of the Mayo Clinic AAA Registry.
At 30 days, 24% of women experienced complications after EVAR, compared with 15% of men (P value = .003). On the other hand, death at 30 days was similar (2.5% vs. 1.5%; P = .41), as was combined early or late death (hazard ratio 1.1 vs. 1.0; P = .36), Dr. Peter Gloviczki reported at the annual meeting. of the Midwestern Vascular Society.
He highlighted a prospective analysis from Albany (N.Y.) Medical College showing that women had significantly higher mortality than did men (3.2% vs. 0.96%, P less than .005) and more frequent colon ischemia, native arterial rupture, and type 1 endoleaks after elective EVAR. There were no sex-related differences, however, for any of these outcomes following elective open repair, emergency EVAR, or surgery (Vasc Surg. 2012 Apr;55:906-13. Epub 2012 Feb. 8).
In the Mayo Clinic analysis, urgent presentation, age over 70 years, and high comorbidity scores were all significantly associated with complications and higher mortality, said Dr. Gloviczki, president of the Society for Vascular Surgery (SVS) and chair emeritus of vascular and endovascular surgery, Mayo Clinic, Rochester, Minn.
The retrospective analysis included 1,002 consecutive patients with abdominal aortic aneurysm (AAA) treated with EVAR at Mayo Clinic from January 1997 to June 30, 2011. Of these, 871 were male (87%) and 131 female (13%). The majority (919) of cases were elective (92%), 43 symptomatic (4%), and 40 ruptured AAA (4%). Patients’ average age was 76 years (range 51-99 years).
Thirty-day mortality was 1% in the elective group, compared with 2.3% in the symptomatic AAA group and 12.5% in the ruptured AAA group (both P less than .0001), he said.
In contrast to the Albany analysis, early mortality after elective repair was similar between men and women (0.75% vs. 2.61%; P = .09). This was further confirmed by multivariate analysis (hazard ratio for all-cause death 1.16; P = .40), despite an increased risk in women for complications (HR 1.67; P = .001) and reinterventions (HR 1.96; P = .002).
High-risk patients, defined by an SVS comorbidity score greater than 10, had significantly higher 30-day mortality after elective EVAR than did low-risk patients (2.33% vs. 0.18%; P = .004).
This was driven by a significantly higher rate of early complications in the high-risk group (19.3% vs. 11.4%), particularly myocardial infarction (1.6% vs. 0.18%) and acute renal failure requiring temporary dialysis (3.26% vs. 1.09%; P less than .05 for all), Dr. Gloviczki observed.
At an average follow-up of 3.2 years, overall survival was significantly higher in patients undergoing elective EVAR vs. symptomatic or ruptured repair (64% vs. 50% and 56%; P less than .001), and in low-risk vs. high-risk elective patients (72% vs. 51%; P less than .001).
Both 30-day mortality and complications significantly increased with age after elective repair, he said.
Overall, there were five late ruptures and nine late conversions, for a complication-free 5-year survival of 64% in the elective group. He noted that access-related difficulties are driving the higher early complication rate in women, but that other factors like age and comorbidities may be at play.
When asked what’s changed in his patient selection and aneurysm size cutoff, Dr. Gloviczki said that in younger patients, surgeons may want to intervene earlier if the aneurysm appears likely to increase in size and is suitable for an endograft, but that overall, age alone should not drive patient selection.
"What this study showed me is that characterizing patients as high risk vs. low risk is important, in addition to age," he said. "As you could see, there was an increased mortality in age, but when we looked at high-risk and low-risk criteria, we only lost one patient in the low-risk group. So age alone does not put you into a high-risk category, it is your additional cardiac, pulmonary and renal disease that does."
Dr. Gloviczki reported no conflicts.
I was impressed with Dr. Gloviczki’s report of the Mayo Clinic experience with 1002 consecutive EVAR procedures. Covering nearly 15 years of consecutive patient accrual in their AAA Registry, it spans virtually the entire EVAR era from the early learning curve phase through adjustments in devices, indications and practice up to 2011. Notable were exemplary 1% and 12.5% 30-day mortality rates for elective and ruptured AAA, respectively. Patients with SVS comorbidity scores <10 had an incredibly low operative mortality rate of 0.18% after elective EVAR compared to 2.33% for the higher-risk cohort.
| Dr. Donaldson |
A relatively low proportion (13%) of women were treated. In distinction to some series, the Mayo experience did not reveal a clear difference (P = 0.09) in early and late mortality rates for women and men after elective EVAR despite a significant increase in risk for complications and reinterventions among women. Even if larger cohorts of women add strength to the mortality findings, the message is clear that women are special. As Dr. Gloviczki mentioned, the overall complication rate of 24% among the 131 women likely relates in part to access problems via small and diseased iliac arteries, consistent with the experience of many of us. Other anatomic features more common in women such as increased tortuosity of the aortic neck related to vertebral compression and collapse may deserve research. The Mayo report should serve to reinforce an element of caution with regard to selection and management of women who appear to be candidates for EVAR.
Dr. Magruder C. Donaldson is Chairman of Surgery at Metrowest Medical Center in Framingham, Mass., and an associate medical editor for Vascular Specialist.
I was impressed with Dr. Gloviczki’s report of the Mayo Clinic experience with 1002 consecutive EVAR procedures. Covering nearly 15 years of consecutive patient accrual in their AAA Registry, it spans virtually the entire EVAR era from the early learning curve phase through adjustments in devices, indications and practice up to 2011. Notable were exemplary 1% and 12.5% 30-day mortality rates for elective and ruptured AAA, respectively. Patients with SVS comorbidity scores <10 had an incredibly low operative mortality rate of 0.18% after elective EVAR compared to 2.33% for the higher-risk cohort.
| Dr. Donaldson |
A relatively low proportion (13%) of women were treated. In distinction to some series, the Mayo experience did not reveal a clear difference (P = 0.09) in early and late mortality rates for women and men after elective EVAR despite a significant increase in risk for complications and reinterventions among women. Even if larger cohorts of women add strength to the mortality findings, the message is clear that women are special. As Dr. Gloviczki mentioned, the overall complication rate of 24% among the 131 women likely relates in part to access problems via small and diseased iliac arteries, consistent with the experience of many of us. Other anatomic features more common in women such as increased tortuosity of the aortic neck related to vertebral compression and collapse may deserve research. The Mayo report should serve to reinforce an element of caution with regard to selection and management of women who appear to be candidates for EVAR.
Dr. Magruder C. Donaldson is Chairman of Surgery at Metrowest Medical Center in Framingham, Mass., and an associate medical editor for Vascular Specialist.
I was impressed with Dr. Gloviczki’s report of the Mayo Clinic experience with 1002 consecutive EVAR procedures. Covering nearly 15 years of consecutive patient accrual in their AAA Registry, it spans virtually the entire EVAR era from the early learning curve phase through adjustments in devices, indications and practice up to 2011. Notable were exemplary 1% and 12.5% 30-day mortality rates for elective and ruptured AAA, respectively. Patients with SVS comorbidity scores <10 had an incredibly low operative mortality rate of 0.18% after elective EVAR compared to 2.33% for the higher-risk cohort.
| Dr. Donaldson |
A relatively low proportion (13%) of women were treated. In distinction to some series, the Mayo experience did not reveal a clear difference (P = 0.09) in early and late mortality rates for women and men after elective EVAR despite a significant increase in risk for complications and reinterventions among women. Even if larger cohorts of women add strength to the mortality findings, the message is clear that women are special. As Dr. Gloviczki mentioned, the overall complication rate of 24% among the 131 women likely relates in part to access problems via small and diseased iliac arteries, consistent with the experience of many of us. Other anatomic features more common in women such as increased tortuosity of the aortic neck related to vertebral compression and collapse may deserve research. The Mayo report should serve to reinforce an element of caution with regard to selection and management of women who appear to be candidates for EVAR.
Dr. Magruder C. Donaldson is Chairman of Surgery at Metrowest Medical Center in Framingham, Mass., and an associate medical editor for Vascular Specialist.
MILWAUKEE – Although female sex is associated with a higher rate of complications, women did not have significantly lower long-term survival after endovascular abdominal aortic aneurysm repair in a review of the Mayo Clinic AAA Registry.
At 30 days, 24% of women experienced complications after EVAR, compared with 15% of men (P value = .003). On the other hand, death at 30 days was similar (2.5% vs. 1.5%; P = .41), as was combined early or late death (hazard ratio 1.1 vs. 1.0; P = .36), Dr. Peter Gloviczki reported at the annual meeting. of the Midwestern Vascular Society.
He highlighted a prospective analysis from Albany (N.Y.) Medical College showing that women had significantly higher mortality than did men (3.2% vs. 0.96%, P less than .005) and more frequent colon ischemia, native arterial rupture, and type 1 endoleaks after elective EVAR. There were no sex-related differences, however, for any of these outcomes following elective open repair, emergency EVAR, or surgery (Vasc Surg. 2012 Apr;55:906-13. Epub 2012 Feb. 8).
In the Mayo Clinic analysis, urgent presentation, age over 70 years, and high comorbidity scores were all significantly associated with complications and higher mortality, said Dr. Gloviczki, president of the Society for Vascular Surgery (SVS) and chair emeritus of vascular and endovascular surgery, Mayo Clinic, Rochester, Minn.
The retrospective analysis included 1,002 consecutive patients with abdominal aortic aneurysm (AAA) treated with EVAR at Mayo Clinic from January 1997 to June 30, 2011. Of these, 871 were male (87%) and 131 female (13%). The majority (919) of cases were elective (92%), 43 symptomatic (4%), and 40 ruptured AAA (4%). Patients’ average age was 76 years (range 51-99 years).
Thirty-day mortality was 1% in the elective group, compared with 2.3% in the symptomatic AAA group and 12.5% in the ruptured AAA group (both P less than .0001), he said.
In contrast to the Albany analysis, early mortality after elective repair was similar between men and women (0.75% vs. 2.61%; P = .09). This was further confirmed by multivariate analysis (hazard ratio for all-cause death 1.16; P = .40), despite an increased risk in women for complications (HR 1.67; P = .001) and reinterventions (HR 1.96; P = .002).
High-risk patients, defined by an SVS comorbidity score greater than 10, had significantly higher 30-day mortality after elective EVAR than did low-risk patients (2.33% vs. 0.18%; P = .004).
This was driven by a significantly higher rate of early complications in the high-risk group (19.3% vs. 11.4%), particularly myocardial infarction (1.6% vs. 0.18%) and acute renal failure requiring temporary dialysis (3.26% vs. 1.09%; P less than .05 for all), Dr. Gloviczki observed.
At an average follow-up of 3.2 years, overall survival was significantly higher in patients undergoing elective EVAR vs. symptomatic or ruptured repair (64% vs. 50% and 56%; P less than .001), and in low-risk vs. high-risk elective patients (72% vs. 51%; P less than .001).
Both 30-day mortality and complications significantly increased with age after elective repair, he said.
Overall, there were five late ruptures and nine late conversions, for a complication-free 5-year survival of 64% in the elective group. He noted that access-related difficulties are driving the higher early complication rate in women, but that other factors like age and comorbidities may be at play.
When asked what’s changed in his patient selection and aneurysm size cutoff, Dr. Gloviczki said that in younger patients, surgeons may want to intervene earlier if the aneurysm appears likely to increase in size and is suitable for an endograft, but that overall, age alone should not drive patient selection.
"What this study showed me is that characterizing patients as high risk vs. low risk is important, in addition to age," he said. "As you could see, there was an increased mortality in age, but when we looked at high-risk and low-risk criteria, we only lost one patient in the low-risk group. So age alone does not put you into a high-risk category, it is your additional cardiac, pulmonary and renal disease that does."
Dr. Gloviczki reported no conflicts.
MILWAUKEE – Although female sex is associated with a higher rate of complications, women did not have significantly lower long-term survival after endovascular abdominal aortic aneurysm repair in a review of the Mayo Clinic AAA Registry.
At 30 days, 24% of women experienced complications after EVAR, compared with 15% of men (P value = .003). On the other hand, death at 30 days was similar (2.5% vs. 1.5%; P = .41), as was combined early or late death (hazard ratio 1.1 vs. 1.0; P = .36), Dr. Peter Gloviczki reported at the annual meeting. of the Midwestern Vascular Society.
He highlighted a prospective analysis from Albany (N.Y.) Medical College showing that women had significantly higher mortality than did men (3.2% vs. 0.96%, P less than .005) and more frequent colon ischemia, native arterial rupture, and type 1 endoleaks after elective EVAR. There were no sex-related differences, however, for any of these outcomes following elective open repair, emergency EVAR, or surgery (Vasc Surg. 2012 Apr;55:906-13. Epub 2012 Feb. 8).
In the Mayo Clinic analysis, urgent presentation, age over 70 years, and high comorbidity scores were all significantly associated with complications and higher mortality, said Dr. Gloviczki, president of the Society for Vascular Surgery (SVS) and chair emeritus of vascular and endovascular surgery, Mayo Clinic, Rochester, Minn.
The retrospective analysis included 1,002 consecutive patients with abdominal aortic aneurysm (AAA) treated with EVAR at Mayo Clinic from January 1997 to June 30, 2011. Of these, 871 were male (87%) and 131 female (13%). The majority (919) of cases were elective (92%), 43 symptomatic (4%), and 40 ruptured AAA (4%). Patients’ average age was 76 years (range 51-99 years).
Thirty-day mortality was 1% in the elective group, compared with 2.3% in the symptomatic AAA group and 12.5% in the ruptured AAA group (both P less than .0001), he said.
In contrast to the Albany analysis, early mortality after elective repair was similar between men and women (0.75% vs. 2.61%; P = .09). This was further confirmed by multivariate analysis (hazard ratio for all-cause death 1.16; P = .40), despite an increased risk in women for complications (HR 1.67; P = .001) and reinterventions (HR 1.96; P = .002).
High-risk patients, defined by an SVS comorbidity score greater than 10, had significantly higher 30-day mortality after elective EVAR than did low-risk patients (2.33% vs. 0.18%; P = .004).
This was driven by a significantly higher rate of early complications in the high-risk group (19.3% vs. 11.4%), particularly myocardial infarction (1.6% vs. 0.18%) and acute renal failure requiring temporary dialysis (3.26% vs. 1.09%; P less than .05 for all), Dr. Gloviczki observed.
At an average follow-up of 3.2 years, overall survival was significantly higher in patients undergoing elective EVAR vs. symptomatic or ruptured repair (64% vs. 50% and 56%; P less than .001), and in low-risk vs. high-risk elective patients (72% vs. 51%; P less than .001).
Both 30-day mortality and complications significantly increased with age after elective repair, he said.
Overall, there were five late ruptures and nine late conversions, for a complication-free 5-year survival of 64% in the elective group. He noted that access-related difficulties are driving the higher early complication rate in women, but that other factors like age and comorbidities may be at play.
When asked what’s changed in his patient selection and aneurysm size cutoff, Dr. Gloviczki said that in younger patients, surgeons may want to intervene earlier if the aneurysm appears likely to increase in size and is suitable for an endograft, but that overall, age alone should not drive patient selection.
"What this study showed me is that characterizing patients as high risk vs. low risk is important, in addition to age," he said. "As you could see, there was an increased mortality in age, but when we looked at high-risk and low-risk criteria, we only lost one patient in the low-risk group. So age alone does not put you into a high-risk category, it is your additional cardiac, pulmonary and renal disease that does."
Dr. Gloviczki reported no conflicts.
Major Finding: Death rates were similar between women and men at 30 days (2.5% vs. 1.5%) as were rates for combined early or late death (hazard ratio 1.1 vs. 1.0).
Data Source: The study is a database review of 1,002 consecutive patients in the Mayo Clinic AAA Registry.
Disclosures: Dr. Gloviczki and his coauthors reported no relevant conflicts of interest.
