The Impact Sex-Related Differences of Infrarenal Aortic Neck Morphology on Endovascular Aneurysm Repair for Similar-Sized Aortic Aneurysms
Authors: Martinelli Ombretta , Marzano Antonio , Bellini Maria Irene , Gattuso Roberto , Di Marzo Luca , Gonta Valeria , Jabbour Jihad , Mansour Wassim , Cuozzo Simone 
Published: December 2024

Objectives: the purpose of this study was to determine whether gender-related proximal neck anatomic variables influence the applicability and outcomes of aortic endografting in women with abdominal aortic aneurysms of similar size. Methods: this retrospective study includes all consecutive patients who underwent elective EVAR for abdominal aortic aneurysms (AAA) with a maximum diameter ranging from 5.0 to 6.0 cm between January 2019 and December 2023. Results: a total of 117 patients were consecutively enrolled between January 2019 and December 2023, comprising 56 females (47.9%) and 61 males (52.1%). Females were older than males (mean age: 78.2 vs. 74.3 years, respectively; p&lt;0.001). Hostile anatomic features of the proximal aortic neck were observed more frequently in women than in men (33.9% vs. 16.3%; p&lt;0.01), including neck length &lt;10 mm (30.3% vs. 10%; p&lt;0.01) and/or a diameter at the seal zone &gt;28 mm (10.7% vs. 3.3%; p&lt;0.01). Women also exhibited a higher frequency of neck angulation &gt;60&deg; compared to men, although this difference was not statistically significant (7.1% vs. 6.6%; p&lt;0.2). No significant sex-based differences were observed concerning the presence of circumferential calcification/thrombosis &gt;50% or a conical neck shape. Technical success was achieved in 98.2% of women and 98.3% of men. Similarly, no significant differences were found between sexes regarding proximal neck-related complications, re-interventions, or open conversions due to these complications.Due to the more challenging aortic neck anatomy, endografts with suprarenal fixation were used more frequently in women than in men (46.4% vs. 30%; p&lt;0.01). Additionally, a significantly higher proportion of EVAR procedures performed outside the IFU were observed in women compared to men (26.7% vs. 18%; p&lt;0.01). Univariate analysis revealed that off-IFU procedures were associated with a significantly higher risk of type IA endoleak and endoleak-related interventions (p&lt;0.001). However, the rate of complications following off-label procedures did not significantly differ between men and women. Conclusions: A more complex and even hostile aortic neck anatomy was observed in women compared to men in our series, despite matched AAA sizes. The more challenging proximal neck features may have led to more frequent supra-renal fixation of the stent graft and off-label EVAR procedures performed in women than in men. Despite a statistically significant higher incidence of type 1A endoleaks following EVAR performed outside the IFU, the outcomes were comparable between genders. Accurate endograft selection and the availability of more versatile devices have improved the feasibility of EVAR, reducing complications related to proximal seal zones caused by the hostile aortic neck characteristics often associated with the female gender.