Endovascular versus open repair for aortoiliac occlusive disease - nationwide in-hospital outcomes by sex.

Background: Evidence comparing endovascular therapy and open surgery for aorto-iliac occlusive disease remains limited, particularly for early complications, resource use, and sex-specific outcomes. Patients and methods: We conducted a retrospective nationwide cohort study using the 2023 German inpatient dataset. Adult hospitalisations with major endovascular or open aorto-iliac reconstructive procedures and arterial occlusive disease were included. Hospitalisations with aneurysm, dissection, or combined procedure codes were excluded. Outcomes included in-hospital mortality, myocardial infarction, ischaemic stroke, major adverse cardiovascular and cerebrovascular events (MACCE), complications, length of stay, and reimbursement. Adjusted estimates were obtained employing a doubly robust estimator using machine learning algorithms and were stratified by sex. Results: Among 2,710 hospitalisations, 1,923 (71.0%) underwent open surgery and 787 (29.0%) endovascular therapy; 41.3% involved women. Endovascular therapy was associated with lower adjusted risks of in-hospital mortality (RR .44, 95% CI .31-.64), MACCE (RR .47, 95% CI .34-.64), acute kidney injury (RR .38, 95% CI .29-.50), major bleeding (RR .36, 95% CI .25-.51), prolonged ventilation (RR .28, 95% CI .18-.43), and SAEs (RR .46, 95% CI .33-.65). Length of stay was shorter after endovascular therapy (-8.57 days, 95% CI -9.63 to -7.52), while reimbursement did not differ significantly. Sex-stratified estimates were more pronounced in men but exploratory without interaction testing. Conclusions: Endovascular therapy was associated with lower in-hospital morbidity and mortality and shorter hospital stay than open surgery, with similar reimbursement. Case-based data lacked longitudinal follow-up and detailed clinical, anatomical and treatment-selection information, limiting causal and patient-level interpretation.