Abdominal aortic aneurysm (AAA) is more common in men, yet women with AAA typically present at older ages, rupture at smaller diameters, and experience higher rupture-related mortality [1, 2]. Endovascular aneurysm repair (EVAR) has become the preferred treatment for anatomically suitable infrarenal AAA over the past two decades [3], with expanding adoption of fenestrated and branched devices for more complex anatomy [4, 5]. However, whether women derive comparable benefits from EVAR remains uncertain. Multiple studies and meta-analyses have shown that women experience higher perioperative mortality, limb ischemia, renal and cardiac complications, and inferior long-term survival after EVAR compared with men [2, 6, 7].

Sex-related anatomical and physiological differences likely contribute to these disparities. Women generally have smaller-caliber iliofemoral arteries, greater vessel tortuosity, and more angulated or hostile proximal necks, which increase the risk of access injury, bleeding, and endograft-related complications [4, 7, 8]. Women also tend to present later in life and with more advanced disease, largely because screening programmes historically target men and overall awareness among both clinicians and women remains low. Although current guidelines already recommend a lower intervention threshold for women (50 mm) in infrarenal AAA, this adjustment does not fully compensate for sex-based anatomical differences, and evidence does not support repair below established thresholds. For thoracic and thoraco-abdominal aneurysms, similar thresholds are applied to both sexes, although the supporting data remain limited. Body-size–adjusted indices may theoretically refine risk stratification, but their clinical utility has not yet been demonstrated [1, 3]. These anatomical and systemic factors may reduce EVAR eligibility and worsen procedural outcomes [6, 9].

Although previous reviews have examined sex differences in AAA repair, most have combined EVAR and open repair or relied on older device-era data, thereby obscuring EVAR-specific disparities [2]. Women also remain substantially underrepresented in major vascular registries and clinical trials, limiting the precision and generalisability of sex-stratified outcome estimates [8, 10]. With increasing emphasis on personalised aortic care and guideline recommendations highlighting the importance of sex-specific considerations [3], an updated synthesis of sex-based outcomes after contemporary EVAR is needed.

This systematic review therefore evaluates sex-based differences in perioperative and long-term outcomes after standard infrarenal EVAR, and provides a secondary synthesis of outcomes after complex fenestrated/branched EVAR, integrating evidence published between 2000 and 2025. The aim is to quantify disparities and to identify anatomical and procedural contributors that may guide sex-aware clinical practice and future research.

This systematic review and narrative synthesis summarizes two decades of evidence (2000–2025) on sex-based differences in outcomes after endovascular abdominal aortic aneurysm repair. Across pooled analyses, registry datasets, and single-centre studies, women consistently demonstrated higher perioperative mortality and morbidity compared with men. The disparity is most evident for access-related complications, cardiorenal events, and complex or ruptured aneurysm presentations. Although several recent large cohorts have reported similar adjusted mortality between sexes, the persistence of excess morbidity in women indicates that sex-based anatomical and physiological differences remain influential determinants of outcome.

Our findings align with and extend previous systematic reviews. The meta-analysis by Liu et al. [6] established that female sex was independently associated with higher 30-day and in-hospital mortality following EVAR, together with increased limb ischemia and renal or cardiac complications. Pouncey et al. [2] similarly found higher short-term mortality and access-related injury among women, although their analysis combined open and endovascular repairs.

The persistent nature of sex-based disparities despite advances in peri-operative care and device technology has also been underscored by Pouncey et al. [18] in a subsequent temporal-trend analysis (2022), which confirmed that the ‘gender gap’ in AAA repair outcomes has not been fully closed.

By focusing specifically on EVAR and complex F/BEVAR and including more contemporary studies, the present review confirms that these differences persist into the current device era despite advancements in stent-graft design, imaging, and operator experience.

The mechanisms underlying these disparities are multifactorial. Anatomically, women have smaller-caliber iliofemoral arteries, greater iliac tortuosity, and more acutely angulated or conical proximal necks. These features complicate device delivery and fixation, increasing the risk of access injury, bleeding, endoleak, and device failure. Moreover, women often present at older ages with a higher comorbidity burden, partly due to screening programmes historically targeting men and intervention thresholds based on absolute aneurysm diameter rather than aortic size index [1]. Systematic under-recognition and delayed referral likely contribute to higher perioperative risk and reduced long-term survival.

While technological progress and improved perioperative care have narrowed the mortality gap, they have not eliminated sex disparities in morbidity. Registry and claims data [1, 4, 8, 12, 14] suggest that women experience more bleeding and access-related complications even when adjusted for confounders, underscoring the importance of proactive preoperative access assessment and selective use of surgical or endovascular conduits. In complex EVAR [5, 11, 13, 17], women continue to exhibit approximately twofold higher perioperative mortality and major complication rates, reflecting the cumulative effect of challenging anatomy, limited device compatibility, and older age. For ruptured aneurysms [14, 15], women remain disadvantaged, with early mortality often exceeding 25% despite endovascular treatment and long-term survival remains inferior.

Beyond infrarenal and pararenal EVAR, emerging evidence from thoraco-abdominal and inner branch endovascular repair indicates that endovascular approaches can achieve acceptable results even in extensive aneurysms [19, 20]. However, sex-specific outcomes have not yet been explored in this setting. Understanding whether the sex-based disparities observed in infrarenal EVAR also extend to thoraco-abdominal repairs remains an important research need.

In addition, frailty has emerged as an independent determinant of perioperative and long-term outcomes after complex EVAR [21, 22]. Frailty captures physiologic vulnerability beyond chronological age and anatomical complexity, yet current literature rarely stratifies its impact by sex. Future studies should evaluate whether frailty exerts differential prognostic effects in women versus men, given the interaction between biological sex, comorbidity, and recovery potential.

These findings have important clinical implications. They reinforce the need for sex-aware imaging, planning, and surveillance strategies, including careful evaluation of iliofemoral access and proximal neck configuration before EVAR, and consideration of individualized thresholds for intervention based on aortic size index. Device manufacturers should prioritize low-profile delivery systems and designs optimized for smaller access vessels. In research, systematic sex- and frailty-stratified reporting should become standard, with adequate female representation in registries and trials to improve the validity of risk prediction models. Moreover, building on the experience of international, web-based initiatives such as the RIVAS survey [23], future research should include a dedicated, multicentre survey among vascular surgeons to assess awareness of sex-based differences in aortic diseases and to explore how perceived gender-related risk modifies clinical decision-making, patient selection, and procedural strategy in contemporary aortic practice.

Despite inherent limitations, mainly the predominance of observational designs, heterogeneous adjustment, and limited female representation, the consistency of findings across independent cohorts supports the robustness of these conclusions.

In summary, women undergoing EVAR experience higher early morbidity and often worse long-term outcomes compared with men, even in contemporary practice. Whether similar disparities exist in thoraco-abdominal endovascular repair remains to be established. Integrating sex and frailty assessment into patient selection, device development, and follow-up strategies will be essential steps toward genuinely personalized aortic care.

Over the last two decades, the body of evidence consistently demonstrates that women undergoing EVAR repair remain at higher risk of perioperative complications and often experience inferior long-term outcomes compared with men. Although advances in imaging, device design, and operator experience have narrowed mortality gaps in some settings, anatomical, biological, and systemic factors continue to drive outcome disparities.

These differences extend beyond infrarenal repair, raising important questions for complex [24] and thoraco-abdominal endovascular procedures, where early results appear encouraging but sex-specific outcomes remain largely unexplored, despite reported cases in the literature of highly complex endovascular procedures performed in women [25]. Moreover, the growing recognition of frailty as a determinant of prognosis suggests that future analyses should stratify outcomes by both sex and frailty status, to capture the true interplay between vascular anatomy, physiological reserve, and procedural risk.

Achieving equity in aortic care will require concerted efforts at multiple levels: refining anatomical thresholds and device instructions for use to account for sex-based variation, ensuring balanced recruitment in clinical trials, and standardizing sex-stratified and frailty-adjusted reporting in registries and outcome studies. Ultimately, a personalized approach to EVAR, integrating sex, anatomy, frailty, and comorbidity, offers the greatest potential to improve both short- and long-term results. Future device innovation and clinical research should explicitly address these biological and structural determinants to advance truly inclusive, evidence-based aortic repair.

All data supporting the findings of this systematic review are available within the article and its supplementary materials. The datasets analyzed consist exclusively of previously published studies cited in the References section.

AM and SC designed the research study and performed the literature search and data extraction. OM and JJ provided expert input on vascular surgery methodology and contributed to the interpretation of results. FF assisted in data analysis, reference verification, and quality assessment. AM and SC drafted the manuscript. OM, JJ, and FF critically revised it for important intellectual content. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

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This research received no external funding.

The authors declare no conflict of interest.

During the preparation of this work the authors used ChatGPT-5.1 in order to check spelling and grammar. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.31083/RCM47920.