Sex Disparity in Outcomes of Ruptured Abdominal Aortic Aneurysm Repair Driven by In-Hospital Treatment Delays

Linda J. Wang, MD, MBA; Satinderjit Locham, MD; Hanaa Dakour-Aridi, MD; Keith D. Lillemoe, MD; Bryan Clary, MD; Mahmoud B. Malas, MD, MHS


Annals of Surgery. 2019;270(4):630-638. 

In This Article

Abstract and Introduction


Objective: We sought to assess whether sex-related differences in timely repair of ruptured abdominal aortic aneurysm (rAAA) were associated with excess risk of early mortality in women.

Summary Background Data: rAAA is a surgical emergency and timeliness of intervention affects outcomes. A door-to-intervention time of <90 minutes is recommended.

Methods: All rAAA repairs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. Patients were stratified by sex and time-delay cohorts. Univariate and multivariate analyses were performed.

Results: There were 3719 rAAA repairs, of which 797 (21%) were performed in women. Sex did not affect repair type: open versus endovascular (21% females, each). Despite similar presentation delays [median 6 hours (inter quartile range, IQR: 3–16)], admission-to-intervention time was longer for women than men [median 1.5 hours (IQR 1–4] vs 1.2 hours (IQR 1–3), P=0.047]. Overall, 45% of patients had a >90-minute delay from admission to repair, with more women than men experiencing this delay (49% vs 44%, P=0.01). Neither were more likely to undergo transfer for treatment. After risk adjustment, female sex was associated with a 48% increase in 30-day mortality. Sex differences in mortality were no longer observed in patients with intervention delays of ≤90 minutes. In patients with >90-minute delays, a 77% increase in 30-day mortality of women over men was noted.

Conclusions: Nearly half of rAAA patients have a door-to-intervention time longer than recommended societal guidelines. Sex differences in mortality after rAAA repair seem to be driven by in-hospital treatment delays.


Controversy exists regarding the role of sex on outcomes after ruptured abdominal aortic aneurysm (rAAA) repair. Although several studies have shown higher perioperative mortality in women over men in this patient population, others have demonstrated female sex is not predictive of increased risk.[1–4] Furthermore, some have demonstrated increased 30-day death in women after open surgical repair (OSR), but not after endovascular repair (EVAR) of rAAA.[5] Potential etiologies put forth to explain this disparity include sex-related differences in pathophysiology, comorbidities, and anatomic factors.[6] One potential contributor that has received less attention is the health system itself.

Ruptured AAA is a surgical emergency and timeliness of intervention affects outcomes.[7,8] A door-to-intervention time of ≤90 minutes is recommended.[9] For the past 3 decades, there has been a growing literature base to suggest that the way in which women interact with the healthcare system is different from men.[10,11] Delayed care, increased risk of misdiagnosis, and downplaying of symptoms have all been described.[12,13] For the treatment of rAAA, some studies have investigated the role of door-to-intervention times. Fewer have described the role of sex on outcomes and none have evaluated the effect of treatment delays on sex differences in early mortality. To that end, this study investigated whether sex-based differences in treatment delays of rAAA exist and if so, whether such delays are associated with differences in outcomes. We hypothesized that under-recognition of this condition in women would result in delayed intervention and lead to worse outcomes.