Racial and ethnic differences in presentation severity and postoperative outcomes in vascular surgery.

BACKGROUND: We assessed the effect of race and ethnicity on presentation severity and postoperative outcomes in those with abdominal aortic aneurysms (AAAs), carotid artery stenosis (CAS), peripheral arterial disease (PAD), and type B aortic dissection (TBAD). METHODS: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception until December 2020. Two reviewers independently selected randomized controlled trials and observational studies reporting race and/or ethnicity and presentation severity and/or postoperative outcomes for adult patients who had undergone major vascular procedures. They independently extracted the study data and assessed the risk of bias using the Newcastle-Ottawa scale. The meta-analysis used random effects models to derive the odds ratios (ORs) and risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). The primary outcome was presentation severity stratified by the proportion of patients with advanced disease, including ruptured vs nonruptured AAA, symptomatic vs asymptomatic CAS, chronic limb-threatening ischemia vs claudication, and complicated vs uncomplicated TBAD. The secondary outcomes included postoperative all-cause mortality and disease-specific outcomes. RESULTS: A total of 81 studies met the inclusion criteria. Black (OR, 4.18; 95% CI, 1.31-13.26), Hispanic (OR, 2.01; 95% CI, 1.85-2.19), and Indigenous (OR, 1.97; 95% CI, 1.39-2.80) patients were more likely to present with ruptured AAAs than were White patients. Black and Hispanic patients had had higher symptomatic CAS (Black: OR, 1.20; 95% CI, 1.04-1.38; Hispanic: OR, 1.32; 95% CI, 1.20-1.45) and chronic limb-threatening ischemia (Black: OR, 1.67; 95% CI, 1.14-2.43; Hispanic: OR, 1.73; 95% CI 1.13-2.65) presentation rates. No study had evaluated the effect of race or ethnicity on complicated TBAD. All-cause mortality was higher for Black (RR, 1.23; 95% CI, 1.01-1.51), Hispanic (RR, 1.90; 95% CI, 1.57-2.31), and Indigenous (RR, 1.24; 95% CI, 1.12-1.37) patients after AAA repair. Postoperatively, Black (RR, 1.54; 95% CI, 1.19-2.00) and Hispanic (RR, 1.54; 95% CI, 1.31-1.81) patients were associated with stroke/transient ischemic attack after carotid revascularization and lower extremity amputation (RR, 1.90; 95% CI, 1.76-2.06; and RR, 1.69; 95% CI, 1.48-1.94, respectively). CONCLUSIONS: Certain visible minorities were associated with higher morbidity and mortality across various vascular surgery presentations. Further research to understand the underpinnings is required.

A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery.

BACKGROUND: Studies have investigated the effects of gender on vascular surgery care. However, to the best of our knowledge, no comprehensive synthesis of the literature has been performed on the presentation severity and postoperative outcomes for abdominal aortic aneurysms (AAAs), carotid artery stenosis (CAS), peripheral artery disease (PAD), and type B aortic dissection (TBAD). We conducted a systematic review and meta-analysis of the sex and gender differences in the presentation severity and outcomes for patients who had undergone major vascular surgery. METHODS: The MEDLINE, Embase, and Cochrane CENTRAL databases were searched from their inception to December 2020. All observational studies and randomized controlled trials that had evaluated the gender differences in presentation severity or outcomes for patients who had undergone open or endovascular AAA or TBAD repair, carotid endarterectomy or stenting, or lower extremity bypass or angioplasty were included. The presentation severity was defined as follows: AAA (symptomatic or ruptured vs asymptomatic), carotid artery disease (symptomatic vs asymptomatic), PAD (chronic limb-threatening ischemia [CLTI] vs claudication), and TBAD (complicated vs uncomplicated). The postoperative outcomes included long-term mortality, stroke, amputation, revascularization, and graft and/or stent thrombosis. A random effects model was used to derive the odds ratios (ORs), risk ratios (RRs), and 95% confidence intervals (CIs). RESULTS: A total of 236 studies met the inclusion criteria for our systematic review. Of the 236 studies, 86 (n = 2,099,534 patients), 62 (n = 2,300,888 patients), 28 (n = 2,394,143 patients), and 4 (n = 4525 patients) had evaluated the effects of gender on the outcomes for patients with AAA, CAS, PAD, and TBAD, respectively. The female patients were more likely to have presented with a ruptured AAA (OR, 1.18; 95% CI, 1.09-1.28) and CLTI (OR, 1.10; 95% CI, 1.02-1.19) than were the male patients. The all-cause mortality for those with an AAA (RR, 1.35; 95% CI, 1.20-1.52) and those with PAD (RR, 1.14; 95% CI, 1.05-1.23) was higher for the women. However, the female patients with CAS had had lower all-cause mortality (RR, 0.85; 95% CI, 0.76-0.94). No sex differences were found in the TBAD outcomes. CONCLUSIONS: We found that female patients who had undergone vascular surgery were associated with more severe disease at presentation, with a greater proportion of ruptured AAAs and CLTI. This potentially contributes to the higher mortality rates for female patients with AAAs and PAD compared with male patients. Future studies are needed to evaluate the reasons for these disparities, and greater efforts are required to support women in receiving more timely vascular surgical care.