BACKGROUND: Female patients with abdominal aortic aneurysms (AAA) undergoing repair have worse outcomes than males. Textbook outcomes (TO) have been described as a metric to direct quality improvement efforts and assess institutional performance. We investigated sex differences among patients achieving a TO after open (OAR) and endovascular aortic aneurysm repair (EVAR). STUDY DESIGN: Vascular Quality Initiative registry data from 80,948 patients undergoing elective AAA repair was reviewed. TO was defined as absence of major medical/surgical complication, prolonged postoperative length of stay (based on 75th percentile of the cohort), reintervention, or mortality and non-home discharge. EVAR and OAR cohorts were analyzed separately, stratified by TO and sex, and compared based on patient demographics, outcomes, and one-year survival. RESULTS: More males had a TO compared to females (EVAR: 80% vs 67%
OAR: 54% vs 47%, p<
0.001, respectively). Obstacles for achieving TO for females were prolonged POLOS, surgical complications, and non-home discharge. TO was associated with improved one-year survival in EVAR and OAR. High volume center status (based on case volume quartiles) was not associated with TO for EVAR but was associated with TO for males undergoing OAR. CONCLUSIONS: Females are less likely to achieve a TO regardless of surgical approach and have a lower one-year survival than males when they do not. Importantly, when females do achieve a TO, there are no sex differences in one-year survival. TO is as a patient- centered quality standard and provides objective support for patient-provider decision- making and expectations and may serve as a quality metric that should be implemented to mitigate sex disparities. Further investigation utilizing multi-level modeling to examine patient, provider, and facility variables that impact TO is warranted.