Women Have a Lower Rate of Abdominal Aortic Aneurysm Repair and Higher Long-term Aortic-related Mortality Compared With Men in a Population-based Study

Increased mortality has been reported after open or endovascular repair of abdominal aortic aneurysms (AAAs) in women. Our aim was to evaluate the natural history and outcomes of AAAs in women at a population level. A population-based cohort study was conducted (1980-2017) of all patients with AAA based on identification using International Classification of Diseases, 9th or 10th Revision and Current Procedural Terminology codes. The gender-specific incidences of AAAs were initially calculated. Medical records were reviewed to confirm diagnosis and identify late events and clinical reasons for opting against repair. Survival analysis for overall and aortic mortality was performed and stratified based on gender and repair status. There were 1537 patients with AAAs; 381 (25%) were female. The incidence of AAA in women was 4.5 times lower than men (23 vs 105 per 100,000 person-years). Compared with men, women were diagnosed at an older age (80 vs 73 years, P < .001), with smaller initial aneurysm size (4 vs 4.3 cm, P < .001). In 99 of 1537 patients, the initial presentation was with rupture (male:female; 79:20); 14 ruptured AAAs were <5.5 cm, 10 of 14 in women. Median follow-up was 18 years. AAA repair was less frequent in women (26% vs 41%, P < .001); with no change after availability of endovascular repair (16% vs 20%, P = .2), women had similar 30-day mortality from AAA repair (4% vs 5%, P = .5). However, on Kaplan-Meier analysis, aortic and all-cause mortality at 10 and 20 years were highest in women who did not undergo repair of their AAA (NRF, hazard ratio: 3, 95% confidence interval: 1.8-4.5, P < .001) as compared with all men and women who underwent repair (Table). This cumulative incidence of aortic-related death remained significantly higher in NRF when analyzed with non-aortic-related deaths as a competing risk, 15% vs 5%-8% in the other groups. All patients with aortic-related death (both women and men) had refused repair because of older age and risk from comorbidities, except in 2 females with rupture of 4.8 and 5.5 cm AAAs while awaiting repair. AAAs are diagnosed in women almost a decade later than men. In this study, mortality after AAA repair was not inferior in women compared with men; however, the incidence of repair was significantly lower in women. Based on the findings of threefold greater long-term aortic-related mortality in women not undergoing AAA repair, it may be advisable to consider repair in women earlier at a smaller AAA size.