Geschlechtsspezifische Einflüsse auf die Ergebnisse der Gefäßchirurgie

 

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Zusammenfassung

Hintergrund: In dieser Übersicht soll zu geschlechtsspezifischen Unterschieden hinsichtlich Prävalenz, Therapie und Ergebnis bei Patienten mit peripherer arterieller Verschlusskrankheit (paVk), Karotisstenose und Bauchaortenaneurysma (BAA) Stellung genommen werden.

Methodik: Für die Literaturübersicht wurde die Datenbank Medline (PubMed) unter den Schlüsselwörtern „peripheral arterial disease AND gender“, „carotid stenosis AND gender“ und „abdominal aortic aneurysm AND gender“ durchsucht.

Ergebnisse: 1.) Frauen (vorzugsweise schwarze Frauen) mit paVk erfahren eher als Männer ein Bypassversagen oder eine Amputation. Gleichwohl sollte das Geschlecht keinen primären Selektionsfaktor für die Revaskularisationstherapie darstellen; trotz höheren Alters und weiter fortgeschrittener Erkrankung der Frauen ließen sich bei ihnen in publizierten Serien mit infrainguinalen arteriellen Rekonstruktionen Offenheits- und Beinerhaltungsraten erzielen, die sich nicht von denen der Männer unterschieden. 2.) Der Nutzen der Karotis-Endarteriektomie (CEA) bei asymptomatischer Karotisstenose ist für Frauen geringer als für Männer. Registerstudien weisen aber allenfalls für symptomatische Frauen im Vergleich zu Männern ein erhöhtes perioperatives Risiko nach CEA auf, wobei speziell bei Frauen die CEA besser als das Karotis-Stenting abschnitt. 3.) Die Behandlung des BAA zeigt deutliche geschlechtsspezifische Unterschiede, das Risiko der Ruptur ist bei kleinen Aneurysmen bei Frauen deutlich größer, ihre perioperative Letalität nach offener und endovaskulärer Versorgung des nicht rupturierten und rupturierten BAA höher als bei Männern. Trotzdem profitieren auch Frauen von der endovaskulären Versorgung des BAA im Vergleich zum offenen Vorgehen, wenn auch die Rate an endovaskulären Behandlungen bei ihnen aufgrund anatomischer Gegebenheiten geringer als bei Männern ist.

Schlussfolgerung: In der Regel wurden bei den genannten Krankheitsbildern bei Frauen ungünstigere Ergebnisse als bei Männern berichtet. Die Differenzen könnten zum einen biologisch begründet sein oder sie beruhen auf der Tatsache, dass Frauen später als Männer arteriosklerotische Veränderungen entwickeln, die zur Therapie zwingen. Frauen sind damit bei Behandlung älter und mit mehr Risikofaktoren behaftet. Hinzu kommt möglicherweise eine unterschiedliche Verordnung medikamentöser Sekundärprävention des arteriellen Verschlussleidens. Es ist zu fordern, geschlechtsspezifischen Unterschieden in weiteren Studien mehr als bisher nachzugehen.

Abstract

Background: This overview comments on gender-specific differences in prevalence, treatment and outcome in patients with peripheral arterial disease (PAD), carotid stenosis, and abdominal aortic aneurysm (AAA).

Method: For the literature review, the Medline database (PubMed) was searched under the key words “peripheral arterial disease AND gender”, “carotid stenosis AND gender” and “abdominal aortic aneurysm AND gender”.

Results: 1.) Women (preferably black women) with PAD experience rather than men bypass failure or amputation. Nevertheless, gender should not constitute a selection criterion for revascularisation therapy. Despite an older age and more advanced stages of disease in women, infrainguinal arterial reconstructions could achieve, in published series, patency and limb salvage rates which did not differ from those of men. 2.) The benefit of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis is less for women compared with men. However, registries exhibited at best for symptomatic women an increased perioperative risk of CEA compared with men, with CEA especially in women better than carotid artery stenting. The treatment of AAA shows significant gender differences. The risk of rupture for small aneurysms is significantly greater in women compared with men, and they have higher in-hospital mortality rates for both open and endovascular repair of ruptured and intact AAA. Yet women also benefit from endovascular repair of AAA compared to open repair, although their eligibility for endovascular repair is less than that of men due to anatomic conditions.

Conclusion: As a rule, for the mentioned diseases less favourable results were reported in women. This may reflect biological disparities, or the differences are based on the fact that women develop arteriosclerotic changes later in life, requiring treatment in older age, with more advanced disease, and with higher comorbidity than men. In addition gender-related differences in the use of secondary medical prevention of PAD have been described. Future studies on the potential impact of gender on the results of vascular surgery are needed.

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