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Redefining the Operative Threshold in Women with Abdominal Aortic Aneurysms
Afshin Skibba, James Evans, Steven Hopkins, Heesuk R Yoon, Daniel Rush
East Tennessee State University, Johnson City, TN

BACKGROUND: Rupture of an abdominal aortic aneurysm (AAA) is a usually fatal event best prevented by timely diagnosis and surgical intervention. Evidence is accumulating that women tend to rupture AAAs at smaller sizes than men, are often at higher risk because of age and comorbidities, and have poorer outcomes. In the past, women were often excluded from lower risk endovascular aortic aneurysm repair (EVAR) because of inadequate iliac vascular access. Furthermore, current elective operative recommendations for asymptomatic AAA repair of >5.5cm do not distinguish possible differences between men and women regarding the advantages of earlier treatment with respect to the risk of rupture relative to AAA size.
METHODS: All patients evaluated with ICD-9 diagnosis codes for AAAs at a single institution between 2000 and 2012 were identified for retrospective analysis under IRB approval.
RESULTS: A total of 3800 patients were identified with a diagnosis of AAA. Of these, there were 3,686 (97%) patients with non-ruptured AAAs, and 114 (3%) patients with ruptured AAAs. The male:female ratios for non-ruptured and ruptured AAAs were similar (2.9:1 and 2.5:1, respectively) as were the percentages of ruptured AAAs for men and women (2.9% and 3.4%, respectively). Hospital mortality rates for ruptured AAAs in men and women were also similar (42.0% for men and 42.4% for women). AAA diameter at the time of rupture was determined in 75 patients (54 men and 21 women). The mean ruptured AAA diameter for men was 7.9 ± 1.6cm (range 4.5 - 12.0cm), and for women was 6.5 ± 1.5cm (range 3.6 - 9.0cm). Of the ruptured AAA patients, 97.3% were treated with emergent open AAA repair and 2.7% by emergent EVAR. The percentage of patients with a ruptured AAA < 5.5 cm in diameter was 28.6% for women and only 3.7% for men (Figure 1 - Percentage Rupture with 5.5cm Threshold).

CONCLUSIONS: Although this single institution experience is small, these results strongly indicate that women tend to rupture AAA's at smaller diameters than men. Mortality for elective EVAR has dramatically decreased AAA operative risk, and the newer low-profile delivery systems have made this technology routinely available for women. Current recommendations for elective operative intervention for AAAs should be reconsidered and stratified by gender.

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