{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,6]],"date-time":"2026-06-06T15:44:11Z","timestamp":1780760651988,"version":"3.54.1"},"reference-count":33,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2023,6,28]],"date-time":"2023-06-28T00:00:00Z","timestamp":1687910400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: There is significant debate regarding the existence of sex-related differences in the presentation, treatment, and outcomes of men versus women affected by abdominal aortic aneurysm (AAA). The purpose of this study is to compare endovascular aneurysm repair (EVAR) of infrarenal AAAs with the current sex-neutral 5.0\u20135.5 cm-diameter threshold for intervention between the two sexes. Methods: Retrospective review of consecutive cases from a single teaching institution over a period of five years of patients who had undergone elective EVAR for AAAs between 5.0 and 5.5 cm in diameter. Outcomes of interest were compared according to sex. Results: Ninety-four patients were included in the analysis, with a higher prevalence of men (53%). Females were older at the time of repair, 78 \u00b1 5.1 years, versus 71.7 \u00b1 7 years (p &lt; 0.01), and had higher incidence of underlying comorbidities, namely, arrhythmia, chronic kidney disease, and previous carotid revascularization. Women had higher incidence of immediate systemic complications (p = 0.021), post-operative AMI (p = 0.001), arrhythmia (p = 0.006), pulmonary oedema (p &lt; 0.001), and persistent renal dysfunction (p = 0.029). Multivariate analysis for post-operative factors associated to mortality and adjusted for sex confirmed that AMI (p = 0.015), arrhythmia (p = 0.049), pulmonary oedema (p = 0.015), persistent renal dysfunction (p &lt; 0.001), cerebral ischemia (p &lt; 0.001), arterial embolism of lower limbs (p &lt; 0.001), and deep-vein thrombosis of lower limbs (p &lt; 0.001) were associated to higher EVAR-related mortality; a higher incidence of post-operative AMI (p = 0.014), pulmonary edema (p = 0.034), and arterial embolism of lower limbs (p = 0.046) were associated to higher 30-days mortality. In females there was also a higher rate of suprarenal fixation (p = 0.026), insertion outside the instruction for use (p = 0.035), and a more hostile neck anatomy with different proximal aortic diameter (p &lt; 0.001) and angle (p = 0.003). Conclusions: A similar threshold of size of AAA for elective surgery for both males and females might not be appropriate for surgical intervention, as females tend to have worse outcomes. Further population-based studies are needed to guide on sex-related differences and intervention on AAA.<\/jats:p>","DOI":"10.3390\/jcm12134364","type":"journal-article","created":{"date-parts":[[2023,6,29]],"date-time":"2023-06-29T01:15:47Z","timestamp":1688001347000},"page":"4364","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Elective Endovascular Aneurysm Repair (EVAR) for the Treatment of Infrarenal Abdominal Aortic Aneurysms of 5.0\u20135.5 cm: Differences between Men and Women"],"prefix":"10.3390","volume":"12","author":[{"given":"Ombretta","family":"Martinelli","sequence":"first","affiliation":[{"name":"Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simone","family":"Cuozzo","sequence":"additional","affiliation":[{"name":"Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesca","family":"Miceli","sequence":"additional","affiliation":[{"name":"Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roberto","family":"Gattuso","sequence":"additional","affiliation":[{"name":"Department of General and Speciality Surgery, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5709-2530","authenticated-orcid":false,"given":"Vito","family":"D\u2019Andrea","sequence":"additional","affiliation":[{"name":"Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0198-7930","authenticated-orcid":false,"given":"Paolo","family":"Sapienza","sequence":"additional","affiliation":[{"name":"Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0730-4923","authenticated-orcid":false,"given":"Maria Irene","family":"Bellini","sequence":"additional","affiliation":[{"name":"Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,6,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1006","DOI":"10.1016\/j.jvs.2016.08.100","article-title":"Sex differences in mortality and morbidity following repair of intact abdominal aortic aneurysms","volume":"65","author":"Deery","year":"2017","journal-title":"J. Vasc. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1261","DOI":"10.1016\/j.jvs.2012.11.039","article-title":"Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England","volume":"57","author":"Lo","year":"2013","journal-title":"J. Vasc. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.ejvs.2018.09.020","article-title":"Editor\u2019s Choice\u2014European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms","volume":"57","author":"Wanhainen","year":"2019","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"794","DOI":"10.14740\/jocmr4376","article-title":"Gender-Based Differences in Abdominal Aortic Aneurysm Rupture: A Retrospective Study","volume":"12","author":"Malayala","year":"2020","journal-title":"J. Clin. Med. Res."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3389\/fsurg.2016.00001","article-title":"The\u2013Not So\u2013Solid 5.5 cm Threshold for Abdominal Aortic Aneurysm Repair: Facts, Misinterpretations, and Future Directions","volume":"3","author":"Kontopodis","year":"2016","journal-title":"Front. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.ejvs.2010.08.026","article-title":"Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): Results from a randomised trial","volume":"41","author":"Cao","year":"2011","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1016\/j.jvs.2009.10.113","article-title":"Positive Impact of Endovascular Options for treating Aneurysms Early (PIVOTAL) Investigators. Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms","volume":"51","author":"Ouriel","year":"2010","journal-title":"J. Vasc. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1177\/0141076819854194","article-title":"Changing the norm towards gender equity in surgery: The women in surgery working group of the Association of Surgeons of Great Britain and Ireland\u2019s perspective","volume":"112","author":"Bellini","year":"2019","journal-title":"J. R. Soc. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e2113749","DOI":"10.1001\/jamanetworkopen.2021.13749","article-title":"Analysis of Female Enrollment and Participant Sex by Burden of Disease in US Clinical Trials Between 2000 and 2020","volume":"4","author":"Steinberg","year":"2021","journal-title":"JAMA Netw. Open"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1607","DOI":"10.1056\/NEJMoa042002","article-title":"A Randomized Trial Comparing Conventional and Endovascular Repair of Abdominal Aortic Aneurysms","volume":"351","author":"Prinssen","year":"2004","journal-title":"N. Engl. J. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"17994","DOI":"10.1038\/s41598-017-18451-2","article-title":"Persisting disparities between sexes in outcomes of ruptured abdominal aortic aneurysm hospitalizations","volume":"7","author":"Stuntz","year":"2017","journal-title":"Sci. Rep."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Cote, C.L., Jessula, S., Kim, Y., Cooper, M., McDougall, G., Casey, P., Dua, A., Lee, M.S., Smith, M., and Herman, C. (2022). Trends in Incidence of Abdominal Aortic Aneurysm Rupture, Repair and Mortality in Nova Scotia. Ann. Vasc. Surg.","DOI":"10.1016\/j.avsg.2022.11.011"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"601","DOI":"10.6002\/ect.2012.0017","article-title":"Emergency Endovascular Repair in a Patient with Abdominal Aortic Aneurysm with Pelvic Transplant Kidneys: Case Report","volume":"10","author":"Smedile","year":"2012","journal-title":"Exp. Clin. Transplant."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1234","DOI":"10.1016\/j.jvs.2021.08.109","article-title":"A significant proportion of current endovascular aortic aneurysm repair practice fails to meet Society for Vascular Surgery clinical practice guideline recommended abdominal aortic aneurysm diameter treatment thresholds in the Vascular Quality Initiative","volume":"75","author":"Scali","year":"2022","journal-title":"J. Vasc. Surg."},{"key":"ref_15","unstructured":"Witzemann, T.M., and Pardue, M.L. (2001). National Academy Press."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1007\/S10016-006-9079-y","article-title":"Gender Differences in Relative Dilatation of Abdominal Aortic Aneurysms","volume":"20","author":"Forbes","year":"2006","journal-title":"Ann. Vasc. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1016\/j.ejvs.2004.11.015","article-title":"Increased Growth Rate of Abdominal Aortic Aneurysms in Women. The Troms\u00f8 Study","volume":"29","author":"Solberg","year":"2005","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1016\/j.jvs.2021.10.040","article-title":"A systematic review and meta-analysis on early mortality after abdominal aortic aneurysm repair in females in urgent and elective settings","volume":"75","author":"Nana","year":"2022","journal-title":"J. Vasc. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2482","DOI":"10.1016\/S0140-6736(17)30639-6","article-title":"Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: Systematic reviews with meta-analysis","volume":"389","author":"Ulug","year":"2017","journal-title":"Lancet"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1016\/j.jvs.2019.06.105","article-title":"Systematic review and meta-analysis of sex differences in outcomes after endovascular aneurysm repair for infrarenal abdominal aortic aneurysm","volume":"71","author":"Liu","year":"2020","journal-title":"J. Vasc. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/j.atherosclerosis.2012.11.008","article-title":"Coronary and carotid atherosclerosis: Similarities and differences","volume":"227","author":"Jashari","year":"2013","journal-title":"Atherosclerosis"},{"key":"ref_22","first-page":"e224","article-title":"Carotid Atherosclerosis in Predicting Coronary Artery Disease","volume":"41","author":"Shenouda","year":"2021","journal-title":"Arter. Thromb. Vasc. Biol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2366","DOI":"10.1016\/S0140-6736(16)31135-7","article-title":"Endovascular versus open repair of abdominal aortic aneurysm in 15-years\u2019 follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): A randomised controlled trial","volume":"388","author":"Patel","year":"2016","journal-title":"Lancet"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1016\/S0140-6736(04)16979-1","article-title":"Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: Randomised controlled trial","volume":"364","author":"Greenhalgh","year":"2004","journal-title":"Lancet"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1011","DOI":"10.1016\/j.jvir.2018.03.002","article-title":"Outcomes over Time in Patients with Hostile Neck Anatomy Undergoing Endovascular Repair of Abdominal Aortic Aneurysm","volume":"29","author":"Bryce","year":"2018","journal-title":"J. Vasc. Interv. Radiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"113.e7","DOI":"10.1016\/j.avsg.2009.04.004","article-title":"Suprarenal Fixation Barbs Can Induce Renal Artery Occlusion in Endovascular Aortic Aneurysm Repair","volume":"24","author":"Subedi","year":"2010","journal-title":"Ann. Vasc. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.jvs.2020.04.508","article-title":"Endurant stent graft demonstrates promising outcomes in challenging abdominal aortic aneurysm anatomy","volume":"73","author":"Mwipatayi","year":"2021","journal-title":"J. Vasc. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1016\/j.avsg.2021.04.032","article-title":"Excluder Stent Graft-Related Outcomes in Patients with Aortic Neck Anatomy Outside of Instructions for Use (IFU) within the Global Registry for Endovascular Aortic Treatment (GREAT): Mid-term Follow-Up Results","volume":"76","author":"Barry","year":"2021","journal-title":"Ann. Vasc. Surg."},{"key":"ref_29","first-page":"252","article-title":"Long-term results of outside \u201cinstructions for use\u201d EVAR","volume":"58","author":"Oliveira","year":"2017","journal-title":"J. Cardiovasc. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"783","DOI":"10.1016\/j.jvs.2018.07.021","article-title":"Patients with large neck diameter have a higher risk of type IA endoleaks and aneurysm rupture after standard endovascular aneurysm repair","volume":"69","author":"Oliveira","year":"2019","journal-title":"J. Vasc. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/j.avsg.2019.01.017","article-title":"Multicenter Registry about the Use of EndoAnchors in the Endovascular Repair of Abdominal Aortic Aneurysms with Hostile Neck Showed Successful but Delayed Endograft Sealing within Intraoperative Type Ia Endoleak Cases","volume":"60","author":"Valdivia","year":"2019","journal-title":"Ann. Vasc. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"346","DOI":"10.1016\/j.avsg.2022.07.030","article-title":"Early Experience with Ovation Alto Stent-Graft","volume":"88","author":"Cuozzo","year":"2023","journal-title":"Ann. Vasc. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1458","DOI":"10.1016\/j.jvs.2013.06.060","article-title":"Comparison of outcomes following endovascular repair of abdominal aortic aneurysms based on size threshold","volume":"58","author":"Keith","year":"2013","journal-title":"J. Vasc. Surg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/13\/4364\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T20:03:01Z","timestamp":1760126581000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/13\/4364"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,6,28]]},"references-count":33,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2023,7]]}},"alternative-id":["jcm12134364"],"URL":"https:\/\/doi.org\/10.3390\/jcm12134364","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,6,28]]}}}