Sex-based outcomes after thoracic endovascular aortic repair: A systematic review and meta-analysis

Objective: As it remains unclear whether there are sex-based differences in clinical outcomes after thoracic endovascular aortic repair (TEVAR), this meta-analysis aimed to evaluate differences in early outcomes and overall survival between female and male patients who underwent TEVAR. Methods: The PubMed, Embase, Web of Science, and Cochrane Central databases were searched for eligible studies published through June 10, 2023, that reported sex-based differences in clinical outcomes after TEVAR. The primary outcome was operative mortality; second outcomes included stroke, spinal cord ischemia, acute kidney injury, hospital length of stay, and overall survival. Patient characteristics, operative data, and early outcomes were aggregated using the random-effects model, presenting pooled risk ratio (RR) or standardized mean difference along with their corresponding 95% confidence intervals (CIs). Overall survival was assessed by reconstructing individual patient data to generate sex- specific pooled Kaplan-Meier curves. This study was registered in PROSPERO (CRD42023426069). Results: Of the 1785 studies retrieved, 14 studies met all eligibility criteria, encompassing a total of 17,374 patients, comprising 5026 female and 12,348 male patients. Female patients were older, had a smaller maximum aortic diameter, had lower rates of smoking and coronary artery disease, and had higher rates of anemia. Intraoperatively, female patients were more likely to use iliac conduits and require blood transfusions. There were no sex-based differences in operative mortality (RR: 1.12,95% CI: 0.90-1.40; P = . 309), stroke (RR: 1.14,95% CI: 0.95-1.38; P = . 165), spinal cord ischemia (RR: 1.33,95% CI: 0.83-2.14; P = . 234), acute kidney injury (RR: 0.78, 95% CI: 0.52-1.17; P = . 228), and hospital length of stay (standardized mean difference: 0.09, 95% CI:-0.03 to 0.20; P = . 141). Pooled Kaplan-Meier estimates showed a worse overall survival in female patients compared with male patients (87.2% vs 89.8% at 2 years, log-rank P = . 001). Conclusions: Among patients treated by TEVAR, female sex was not associated with increased risk of operative mortality or major morbidity. However, female patients exhibited a lower overall survival after TEVAR compared with male patients.