Early Versus Threshold Repair of Women's Abdominal Aortic Aneurysms

Guidelines recommend elective repair of women's abdominal aortic aneurysms (AAAs) at an aortic diameter of ≥5.0 cm, based on limited female data. This study evaluates outcomes of elective repair for small (4-4.99 cm) versus larger (≥5.0 cm) asymptomatic AAAs in women.

Using Vascular Quality Initiative registry data, we performed a retrospective cohort analysis of 15,544 women of ≥50 years undergoing elective open or endovascular aneurysm repair (EVAR) from 2010 to 2023. Propensity scores were estimated within repair strata and applied as stabilized inverse probability of treatment weights (IPTW). Primary outcomes were all-cause mortality (IPTW-weighted Cox), Kaplan-Meier survival at 12, 24, 36, 48, and 60 months, restricted mean survival time (RMST, bootstrap), 30-day mortality, and postoperative cardiovascular and cerebrovascular complications. Secondary outcomes included hospitalization length, endoleak, and odds of open repair.

IPTW-weighted Cox models revealed AAAs ≥5.0 cm versus 4-4.99 cm were associated with higher adjusted all-cause mortality in the EVAR cohort (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.05-1.37; open HR 1.47, 95% CI 0.99-2.16). Sixty-month weighted survival was lower for larger AAAs (EVAR: 79.7% vs. 82.8%; Open: 82.3% vs. 87.1%). RMST to 60 months favored treatment at 4-4.99 cm. Thirty-day mortality, hospitalization length, and postoperative cardiovascular and cerebrovascular complications were similar by diameter. Larger AAAs had higher odds of endoleak (odds ratio [OR] 1.35, 95% CI 1.19-1.53) and of undergoing open repair (OR 1.80, 95% CI 1.56-2.09).

Among women, asymptomatic AAAs ≥5.0 cm were associated with modestly lower 5-year survival and greater odds of endoleak. These findings support individualized decision-making rather than a single diameter cutoff.