Lower Rates of Abdominal Aortic Aneurysm Repair and Higher Long-term Aortic Mortality in Women Compared With Men: Results of a Population-Based Study Spanning 4 Decades

Objective: To determine the population-level impact of screening and endovascular repair as well as mortality in women with abdominal aortic aneurysms (AAAs). Patients and Methods: We conducted a population-based cohort study of patients from Olmsted County, Minnesota, in whom AAA was diagnosed between January 1, 1980, and December 31, 2017. The AAAs were identified using the International Classification of Diseases, Ninth and Tenth Revisions and Current Procedural Terminology codes with medical record review to confirm the diagnosis and identify late events. Survival analysis for overall and aortic mortality was performed and stratified based on sex and repair status. Results: There were 1537 patients in our study cohort (75% [1156] male; median age, 74 years). Compared with men, women were older (80 vs 73 years; P<.001), had smaller initial aneurysm size (4 vs 4.3 cm; P<.001), underwent AAA repair less frequently (26% [99] vs 41% [475]; P<.001), and had similar 30-day mortality from AAA repair (4% [4 of 381] vs 5% [22 of 1156]; P=.50). Median follow-up was 18 years. Aortic and all-cause mortality at 10 and 20 years were highest in females who did not undergo repair (hazard ratio, 3; 95% CI, 1.8 to 4.5; P<.001), as compared with all men and women who underwent AAA repair. Cumulative aortic mortality analyzed with non–aortic-related deaths as a competing risk factor remained significantly higher in NRF (15% [40 of 282] vs 5% to 8% in other groups; 5/99 in females undergoing repair, 39/681 in non repaired males and 37/475 in males who underwent repair, P=.001). All patients with aortic-related mortality had refused repair due to older age and comorbidities, except 2 females with ruptures of 4.8 and 5.5 cm AAAs awaiting repair. Conclusion: Abdominal aortic aneurysms are diagnosed in women almost a decade later and repaired less often than in men. There is a 3-fold greater long-term aortic-related mortality in women not undergoing AAA repair compared with men and women who underwent AAA repair.