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Surgical Bypass Summit — Session 2:
Gender differences in PAD treatment: Is "endovascular first" strategy worse for women? — Venita Chandra, MD

  • Video

Venita Chandra, MD

Although traditionally underrepresented in the literature and underdiagnosed, after age adjustment, women in fact have a higher prevalence of peripheral artery disease (PAD) as compared to men. Despite these findings, women have traditionally undergone revascularization, in particular open revascularization, at lower rates than men.1 With the increasing trend toward endovascular strategies, the question remains whether such disparities continue to exist with this modality.

Several studies have evaluated the role of gender in outcomes from endovascular procedures. A study of a little under 400 men and women examined outcomes from endovascular infrainguinal revascularization that took place from 2001 to 2006.2 The investigators found a similar patency rate between men and women; however, they also noted that women were older, had higher reintervention rates (17% vs 12.3%), and usually presented with limb threat. Another study by Pulli and colleagues3 examined revascularizations that occurred from 2000 to 2010 at their institution,4 and once again found that women tended to be older and have more advanced disease, but no significant difference in lesion location or intervention was found. However, a trend demonstrated poorer results in women.

Gender differences after open surgical bypass have also been demonstrated in a number of studies with variable results. Lancaster et al5 evaluated the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data from 2005 to 2008 to assess predictors of early surgical bypass graft failure. This large study found that being female was an independent risk factor for early graft failure; however, other large studies did not find any difference in terms of primary patency or limb salvage between genders.6

Review of the 2012 NSQIP data (author’s unpublished data analysis) focusing on PAD in men and women revealed that, of the more than 12,000 patients who underwent open (approximately 60%) and endovascular (approximately 40%) revascularizations that year, approximately 60% of the procedures were performed in men and approximately 40% were performed in women. Women had a higher complication rate after endovascular procedures (12% vs 9.9%; P = .017), but no significant difference in 30-day mortality was found. After open procedures, however, women were found to have both higher complication rates (38.9% vs 28.9%; P < .001) and higher 30-day mortality rates (2.8% vs 1.9%; P = .01). The reason for these differences between men and women is unclear; vessel sizing and anatomic distribution in women may be contributing factors.


Differences in outcomes for PAD treatment between women and men exist for both endovascular and open strategies. The issue of gender disparity in PAD treatment outcomes cannot be resolved until there are more studies that specifically address the subject. Therefore, further investigation with specific emphasis on tools and techniques targeted for women is warranted. Until then, consideration must be given to the fact that women have high complication and mortality rates, and consequently current vascular approaches may not be ideal for the female anatomy or common female comorbidities.

Venita Chandra, MD, is from Stanford University in Stanford, California. She has disclosed that she has received compensation from Gore for participating in the Summit and has received honoraria from Gore for writing this article. Dr. Chandra may be reached at

  1. Feinglass J, McDermott MM, Foroohar M, et al. Gender differences in interventional management of peripheral vascular disease: evidence from a blood flow laboratory population. Ann Vasc Surg. 1994;8:343-349.
  2. DeRubertis BG, Vouyouka A, Rhee SJ, et al. Percutaneous intervention for infrainguinal occlusive disease in women: equivalent outcomes despite increased severity of disease compared with men. J Vasc Surg. 2008;48:150-157; discussion 157-158.
  3. Pulli R. Vein versus heparin bonded ePTFE: what do the data really say? Endovascular Today. 2015;14(Suppl):8-9.
  4. Pulli R, Dorigo W, Pratesi G, et al. Gender-related outcomes in the endovascular treatment of infrainguinal arterial obstructive disease. J Vasc Surg. 2012;55:105-112.
  5. Lancaster RT, Conrad MF, Patel VI, et al. Predictors of early graft failure after infrainguinal bypass surgery: a risk-adjusted analysis from the NSQIP. Eur J Vasc Endovasc Surg. 2012;43:549-555.
  6. Ballotta E, Gruppo M, Lorenzetti R, et al. The impact of gender on outcome after infrainguinal arterial reconstructions for peripheral occlusive disease. J Vasc Surg. 2012;56:343-352.