Women Are Less Likely to Experience Textbook Outcomes for AAA Repair

Filiberto AC, Banks CA, Sickels A, Novak Z, et al. Sex Differences in Textbook Outcomes among Adults Undergoing Elective Abdominal Aortic Aneurysm Repair. J Am Coll Surg. April 2025.

Women with abdominal aortic aneurysms (AAAs) undergoing repair have worse outcomes than men. Textbook outcomes (TOs) have been described as a metric to direct quality improvement efforts and assess institutional performance. 

Filiberto et al investigated sex differences among patients achieving a TO after open (OAR) and endovascular aortic aneurysm repair (EVAR).

Vascular Quality Initiative registry data from 80,948 patients undergoing elective AAA repair were reviewed. TO was defined as the absence of major medical or surgical complication, prolonged postoperative length of stay (based on the 75th percentile of the cohort), reintervention, or mortality and nonhome discharge. EVAR and OAR cohorts were analyzed separately, stratified by TO and sex, and compared based on patient demographics, outcomes, and 1-year survival.

More men had a TO compared with women (EVAR 80% versus 67%; OAR 54% versus 47%, p < 0.001, respectively). Obstacles for achieving TO for women were prolonged postoperative length of stay, surgical complications, and nonhome discharge. TO was associated with improved 1-year survival in EVAR and OAR. High-volume center status (based on case volume quartiles) was not associated with TO for EVAR but was associated with TO for men undergoing OAR.

Women are less likely to achieve a TO regardless of surgical approach, and they have a lower 1-year survival than men when they do not. Importantly, when women do achieve a TO, there are no sex differences in 1-year survival.

TO is a patient-centered quality standard that provides objective support for patient-provider decision-making and expectations. It also may serve as a quality metric to help mitigate sex disparities. Further investigation using multilevel modeling to examine patient, provider, and facility variables that affect TO is warranted.