Propensity Score Analysis of Outcomes in Females Undergoing Aneurysm Repair: A Comprehensive Systematic Review

Abstract

BACKGROUND: Sex-related differences in endovascular aneurysm repair (EVAR) outcomes remain significant, with women experiencing higher perioperative mortality and complications. This systematic review and meta-analysis assess sex-specific differences in EVAR outcomes using propensity score-matched (PSM) studies. METHODS: Following PRISMA guidelines, PubMed, Cochrane and Web of Science databases were searched for studies comparing elective EVAR outcomes for non-ruptured aneurysms, where a female-to-male propensity score matching was used to adjust for confounders. The primary outcome was 30-day mortality, pooled using random-effects meta-analysis. Secondary outcomes included complications, hospital length of stay and operative time. RESULTS: Six PSM studies met inclusion criteria, comprising 79,468 patients (65,162 men and 14,306 women). Despite PSM, women had significantly higher 30-day mortality (OR 4.28, 95% CI: 1.02-17.90, I² = 93%). Additionally, women had a higher risk of bowel ischemia (OR 4.477, 95% CI: 1.26-15.92) and renal complications (OR 3.243, 95% CI: 1.11-9.44). Women also had a longer hospital length of stay by an average of 1.8 days, reflecting a more complicated recovery course. However, postoperative respiratory complications were lower in women than in men (OR 0.74, 95% CI: 0.56-0.98). CONCLUSION: Despite the use of PSM to adjust for confounding factors, significant sex-related disparities persist in EVAR outcomes. These findings highlight the potential influence of anatomical differences, procedural challenges and perioperative management strategies that may not be fully accounted for by matching methods. Future investigations should focus on refining patient selection criteria, optimizing perioperative care and improving EVAR device design to enhance outcomes in women.