Investigation of sex-specific discrepancies in peri-operative mortality & morbidity following elective abdominal aortic aneurysm repair: are sex-specific pathways needed to provide equity in delivery of care?
File(s)
Author(s)
Pouncey, Anna Louise
Type
Thesis
Abstract
Research Question:
Why do women experience higher mortality rates than men following elective infrarenal abdominal aortic aneurysm (IRAAA) repair?
Key Findings:
1. Systematic review and meta-analyses identified a higher mortality risk following IRAAA repair for women. Women stayed longer in hospital and more often experienced post-operative complications. Fewer women had pre-operative coronary artery disease but more experienced cardiac complications.
2. A multinational retrospective cohort study investigated sex-differences in standard of care and post-operative major adverse cardiovascular events and death (MACED). 21,810 UK and 8061 Swedish IRAAA repairs were identified. UK women less often attained waiting-time targets and less often received peri-operative medications or secondary cardiovascular risk prevention. Women were at greater risk of MACED in both countries, despite adjustment for risk factors and standard of care.
3. Further analyses using UK and Swedish data demonstrated a consistently slower rate of time to alive hospital discharge for women, despite adjustment for risk factors, standard-of-care and post-operative complications.
4. 1226 computed tomography angiography scans from UK IRAAA patients were examined using fully automated volume segmentation. 128 women were matched to 512 men, adjusting for cardiovascular risk and aortic size index. Women had narrower, shorter, more angulated IRAAA necks, narrower visceral branches and access vasculature, and less often met EVAR specifications. Women had greater thoracic aorta and superior mesenteric artery AWT indices, but did not have increased vessel tortuosity, stenoses, or calcification.
5. A discrete choice experiment explored the effect of patient sex, and other attributes on vascular surgeon’s decision making for IRAAA repair. All else being equal, a woman was more likely to be offered repair. Anaesthetic risk, and hostile anatomy were deterrents. Increasing age did not have significant effect for men but decreased the likelihood of repair for women. Women were more likely to be offered (less invasive) endovascular repair.
Why do women experience higher mortality rates than men following elective infrarenal abdominal aortic aneurysm (IRAAA) repair?
Key Findings:
1. Systematic review and meta-analyses identified a higher mortality risk following IRAAA repair for women. Women stayed longer in hospital and more often experienced post-operative complications. Fewer women had pre-operative coronary artery disease but more experienced cardiac complications.
2. A multinational retrospective cohort study investigated sex-differences in standard of care and post-operative major adverse cardiovascular events and death (MACED). 21,810 UK and 8061 Swedish IRAAA repairs were identified. UK women less often attained waiting-time targets and less often received peri-operative medications or secondary cardiovascular risk prevention. Women were at greater risk of MACED in both countries, despite adjustment for risk factors and standard of care.
3. Further analyses using UK and Swedish data demonstrated a consistently slower rate of time to alive hospital discharge for women, despite adjustment for risk factors, standard-of-care and post-operative complications.
4. 1226 computed tomography angiography scans from UK IRAAA patients were examined using fully automated volume segmentation. 128 women were matched to 512 men, adjusting for cardiovascular risk and aortic size index. Women had narrower, shorter, more angulated IRAAA necks, narrower visceral branches and access vasculature, and less often met EVAR specifications. Women had greater thoracic aorta and superior mesenteric artery AWT indices, but did not have increased vessel tortuosity, stenoses, or calcification.
5. A discrete choice experiment explored the effect of patient sex, and other attributes on vascular surgeon’s decision making for IRAAA repair. All else being equal, a woman was more likely to be offered repair. Anaesthetic risk, and hostile anatomy were deterrents. Increasing age did not have significant effect for men but decreased the likelihood of repair for women. Women were more likely to be offered (less invasive) endovascular repair.
Version
Open Access
Date Issued
2024-02-12
Date Awarded
2024-07-01
Copyright Statement
Creative Commons Attribution NonCommercial Licence
License URL
Advisor
Bicknell, Colin
Powell, Janet
Sponsor
NIHR
Grant Number
NIHR DF 301767
Publisher Department
Department of Surgery & Cancer
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)
Rights Embargo Date
2026-06-30