Thirty-day mortality in females after elective and urgent abdominal aortic aneurysm repair.

Introduction: Female sex is a risk factor of post-operative mortality and morbidity after abdominal aortic aneurysm (AAA) repair. The aim of this systematic review is to assess the sex-specific early mortality following both elective and urgent AAA repair.

Evidence acquisition: The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. Observational studies (2000-2022), of the English medical literature, focusing on early mortality after AAA repair in females under elective or urgent setting were eligible. A systematic search of MEDLINE, EMBASE and CENTRAL databases, was conducted (November 30^th, 2022). The risk of bias was assessed using the Newcastle-Ottawa Scale. Primary outcome was 30-day mortality in relevant strata. A proportional metanalysis was used to assess the estimates.

Evidence synthesis: Seventeen retrospective studies and 83,738 females were included. Thereof 68.7% underwent elective repair while the remaining were managed urgently. Endovascular repair (EVAR) was applied in 37.3% of patients (15.4% urgent) vs. 62.7% with OSR (23.5% urgent). In the total cohort, the perioperative mortality was estimated at 11% (OR, 95% CI: 5-17%, P<0.01, I² 99.92%) while 3% (OR, 95% CI: 0.02-0.03, P<0.01, I² 93.42%) deceased after elective repair (2% OR, 95% CI 0.01-0.02, P<0.01, I² 83.08%, after EVAR and 5% (OR, 95% CI: 0.05-0.06, P<0.01, I² 77.36%, after OSR) and 36% (OR, 95% CI: 0.28-0.44, P<0.01, I² 99.51%) after urgent repair (25% OR, 95% CI: 0.16-0.34, P<0.01, I² 98.45%, after EVAR and 40% (OR, 95% CI: 0.34-0.46, P<0.01, I² 95.96%, after OSR).

Conclusions: AAA repair in females appears to be associated with considerable postoperative mortality. Despite the rapid development of innovative techniques and intensive care of severely ill patients, perioperative mortality after ruptured AAA remains devastatingly high.