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In-Hospital Delays Explain Why Women Are Less Likely to Survive Ruptured AAA

Key findings

  • In this analysis of prospective data on 3,719 patients with ruptured abdominal aortic aneurysm, 45% were treated later than the 90-minute door-to-intervention standard
  • Women were significantly more likely than men to experience that delay (49% vs. 44%; P = .01)
  • Female sex was associated with a 48% increased risk of 30-day mortality, despite similar time from symptom onset to admission
  • No sex-based difference in 30-day mortality was evident among patients treated within 90 minutes of admission
  • Among patients treated beyond the 90-minute benchmark, women were 77% more likely than men to die within 30 days

Some studies of ruptured abdominal aortic aneurysm (rAAA) suggest that perioperative mortality is higher in women. The explanations offered have pointed to sex-related differences in pathophysiology, comorbidities and anatomic factors.

Surgical Resident Linda J. Wang, MD, MBA, of the Division of Vascular and Endovascular Surgery at Massachusetts General Hospital, Mahmoud B. Malas, MD, MHS, of the University of California San Diego, and colleagues hypothesized that one potential contributor to gender differences has been relatively overlooked: the health care system itself. rAAA is a true surgical emergency, and the Society for Vascular Surgery (SVS) recommends a door-to-intervention time of 90 minutes. This is of concern because women appear to interact with the healthcare system differently than men do, sometimes downplaying their symptoms. There is growing evidence that suggests women are at greater risk of delayed care and misdiagnosis.

In Annals of Surgery, Drs. Wang, Malas and colleagues report that sex differences in mortality after rAAA repair seem to be driven by in-hospital treatment delays. They also bring to light that close to half of all patients with rAAA have a door-to-intervention time longer than recommended.

Study Design

The researchers reviewed data that were prospectively collected for the SVS Vascular Quality Initiative between January 2003 and May 2017. They identified 3,719 operative repairs for rAAA: 2,922 in men and 797 in women. 53% of the patients underwent endovascular repair and the others had open surgical repair.

Periprocedural Variables

There were no differences between sexes in:

  • Transfer status (from another facility vs. no transfer)
  • Operative approach (endovascular vs. open)
  • Procedure time
  • Estimated blood loss
  • The overall major complication rate

Primary Endpoint: 30-Day Mortality

The researchers found that the 30-day mortality rate was significantly higher in women than in men: 33% vs. 26% (P < .001). On multivariate analysis, female sex was associated with a 48% increased risk of all-cause 30-day mortality (OR, 1.48; 95% CI, 1.23–1.78; P < .001).

When the cohort was stratified by type of operative approach, female sex was associated with a significant 42% increased risk of 30-day mortality after endovascular repair and a significant 50% increased risk after open repair.

Impact of In-hospital Treatment Delays

  • Women and men had similar delays in time from symptom onset to admission at the treating facility
  • Women had longer delays from admission to operative repair (90 vs. 72 minutes; P = .047)
  • Women were significantly more likely than men to have treatment delays >90 minutes (49% vs. 44%; P = .01)

Door-to-Intervention Time

  • Patients treated within 90 minutes of admission: No increased mortality risk among women, even after the cohort was stratified by the operative approach
  • Patients treated beyond the 90-minute benchmark: 77% higher mortality risk in women (52% higher after endovascular repair; twofold higher after open repair)

The Need for Systemic Change

When women and men were considered together, door-to-intervention times were greater than the 90-minute benchmark in 45%. Thus, the study raises concerns about rAAA triage and treatment for all patients. A nationwide study in the U.S. determined that patients with urgent clinical issues wait in emergency departments for a median of 28 minutes before being seen by a provider.

Meeting the SVS benchmark requires prompt notification of the vascular surgery team and early, rapid transfer, if necessary. A high level of suspicion is needed so that rAAA can be recognized in time, especially in women.

higher risk of death within 30 days for women vs. men after surgery for ruptured abdominal aortic aneurysm

of women with ruptured abdominal aortic aneurysm were not treated within the recommended 90 minutes

higher risk that women would die within 30 days if they had to wait >90 minutes for surgery for ruptured abdominal aortic aneurysm

Learn more about Vascular and Endovascular Surgery at Mass General

Refer a patient to the Mass General Fireman Vascular Center


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