Objective: Previously, reports have shown women experience higher mortality than men after elective open (OAR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA).With recent improvements in overall AAA repair outcomes, this study aimed to identify whether sex-specific disparity has been ameliorated by modern practice, and to define sex-specific differences in peri/post-operative complications and pre-operative status; factors which may contribute to poor outcome.

Methods: Systematic review, meta-analysis and meta-regression of sex-specific differences in 30-day mortality and complications conducted according to PRISMA guidance (Prospero registrationCRD42020176398). Papers with ≥50 women, reporting sex-specific outcomes, following intact primary AAA repair, from 2000-2020 world-wide were included; separate analyses for EVAR and OAR. Data sources: Medline, Embase and CENTRAL databases 2005-2020 searched using ProQuest Dialog™. Results: 26 studies (371,215 men,65,465 women) included. Meta-analysis and meta-regression indicated sex-specific odds ratios(ORs) for 30-day mortality were unchanged from 2000-2020.Mortality risk was higher in women for OAR and more so for EVAR (OR [95%CI] 1.49 [1.37,1.61];1.86 [1.59,2.17] respectively) and remained following multivariable risk-adjustment. Transfusion, pulmonary complications and bowel ischemia were more common in women after OAR and EVAR (OAR: ORs 1.81 [1.60,2.04], 1.40 [1.28,1.53], 1.54 [1.36,1.75]; EVAR: ORs 2.18[2.08,2.29] 1.44 [1.17,1.77], 1.99 [1.51,2.62] respectively). Arterial injury, limb ischemia, renal and cardiac complications were more common in women after EVAR (ORs 3.02 [1.62-5.65], 2.13[1.48-3.06], 1.46 [1.22-1.72] and 1.19[1.03,1.37] respectively); the latter was associated with greater mortality risk on meta-regression. Conclusions: Increased mortality risk for women following AAA repair remains. Women had higher incidence of transfusion, pulmonary and bowel complications after EVAR and OAR. Higher mortality risk ratios for EVAR may result from cardiac complications, additional arterial injury and embolisation, leading to renal and limb ischemia. These findings indicate possible causes for observed outcome disparities and targets for quality improvement.