The Effect of Frailty on Long Term Outcomes in Vascular Surgical Patients

Decision making in the frail vascular surgery patient: A scoping review

Increasing evidence highlights the adverse impact of frailty and reduced physiologic reserve on surgical outcomes. Therefore, identification of frailty is essential for older adults being evaluated for vascular surgery procedures. Numerous frailty assessment tools are available to quantify the level of frailty and assist in preoperative decision making for these older patients. This review evaluates traditional and novel frailty metrics for their scientific validation, limitations, and clinical utility in vascular surgery decision-making.

Association of polypharmacy scores with the long-term survival of patients with intact aortoiliac aneurysms and indication for repair

OBJECTIVE/BACKGROUND

Our study analyzed the relationship between two polypharmacy scores (addition of chronic prescribed drugs [ACPDs] and Rx-Risk Comorbidity Index) and survival in patients with an intact abdominal aortic and/or common iliac aneurysm (AAA).

METHODS

Consecutive retrospective, single-center cohort of patients attended for an intact AAA with indication for repair from 2008 to 2021. Demographic data, Charlson Comorbidity Index, AAA treatment, ACPD, and Rx-Risk polypharmacy scores were recorded at baseline. Main outcomes were the 5-year and long-term survival rates. The statistical analysis included Cox regression, area under the curve, and continuous net reclassification index.

RESULTS

A total of 424 patients with AAA were evaluated (median age: 76 years; 92.2% male, median Charlson index 2), of whom 314 (74.1%) underwent intervention (80% endovascular and 20% open) and 110 (25.9%) did not. During follow-up (mean 4.6 years), 245 patients (57.8%) died, with 1-month, 1-year, and 5-year survival rates of 98.1%, 86.3%, and 52.7%, respectively. ACPD and Rx-Risk indices (median [interquartile range]: 6 [4-9] and 3 [0-5], respectively) were significantly and linearly associated (P < .001) with survival, with the best cutoff points at 5 and 0, respectively. An ACPD >5 (patients with >5 chronically prescribed drugs at baseline) and an Rx-Risk >0 were associated with a 45.2% (P = .038) and 102% (P = .002) increase in 5-year mortality, respectively, after adjustment for age, sex, Charlson index, and type of AAA treatment. Both polypharmacy indices improved significantly the discriminative power of the Charlson Comorbidity Index in predicting survival.

CONCLUSIONS

Both ACPD and Rx-Risk polypharmacy scores are independently related to survival among patients with an intact AAA and indication for repair. Their behavior is similar, so the simple ACPD >5 appears to be sufficient to identify patients with lower survival rates.

A systematic review of frailty assessment tools used in vascular surgery research

OBJECTIVE

Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice.

METHODS

Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed.

RESULTS

Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population.

CONCLUSIONS

Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.

Association of Preoperative Frailty with Inferior Outcomes for Patients Undergoing Lower Extremity Bypass for Chronic Limb Threatening Ischemia: A Systematic Review

BACKGROUND

Frailty is a risk factor associated with adverse postoperative outcomes following lower extremity bypass (LEB) surgery in patients with peripheral arterial disease (PAD). Chronic limb threatening ischemia (CLTI) represents the worst form of PAD, and frailty is common among patients presenting with CLTI. Multiple frailty assessment scores have been developed for the past 2 decades; however, a universal clinical assessment tool for measuring frailty has not yet been established due to the complexity of the concept. This systematic review aimed to evaluate the use of a frailty index as a predictor of postoperative outcomes in patients undergoing LEB.

METHODS

The review protocol was registered in the international prospective register of systematic reviews (PROSPERO) database (CRD42022358888). A systematic literature search was conducted using the PubMed and Scopus databases. The review followed the preferred reporting items for systematic reviews and metaanalyses (PRISMA) guidelines. The risk of bias was evaluated using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. A total of 3,929 studies were initially selected originally and were eventually left with 6 studies that met the inclusion criteria of this systematic review.

RESULTS

Six studies were examined that assessed the relationship between frailty index and long-term mortality following LEB for CLTI were screened. All analyses were published between 2017 and 2020 and included a broad spectrum of patients who underwent LEB. The results of these studies showed inconsistencies in the reporting of postoperative outcomes and the time endpoint of these events. However, all correlated with higher frailty index and increased mortality rate.

CONCLUSIONS

Higher frailty index preoperatively is associated with an increased likelihood of postoperative comorbidities after undergoing LEB. Identifying and addressing the preoperative frailty index of these patients may be a practical approach to reducing postoperative adverse outcomes. A thorough review of the frailty spectrum and standardized reporting of outcomes in the context of frailty could be helpful to have a more comprehensive understanding of this subject.

Frailty is Not Associated with Worse Outcomes following Lower Extremity Angiograms for Limb Ischemia in Nonagenarians

BACKGROUND

Endovascular interventions are performed routinely with minimal risk in younger populations. The safety and efficacy of endovascular interventions in nonagenarians is under examined. We sought to examine the following (1) mortality and limb salvage rates in the nonagenarian population and (2) whether frailty was associated with outcomes following lower extremity (LE) interventions for both acute limb ischemia (ALI) and chronic limb threatening ischemia (CLTI).

METHODS

A retrospective review of patients ≥90 years who underwent a LE angiogram for ALI or CLTI over a 12-year period at a single institution was performed. Primary outcomes were 30-day and 12-month limb salvage and mortality rates. Patient demographics, 30-day complications, and 12-month target vessel reintervention (TVR) were reviewed. Frailty scores were calculated using the 11-factor modified frailty index (MFI-11).

RESULTS

From 2009 to 2021, 76 patients (36% male) with a mean age of 93 (range: 90-102) underwent endovascular procedures for ALI (n = 13) and CLTI (n = 63). 30-day amputation and mortality rates were 6% and 8%, respectively. Patient demographics, preoperative functional status, and TVR rates were not different between patients who had early amputation (≤30 days) and those who achieved limb salvage. Seventy-two patients (94%) had follow-up data at 30 days. There was an 8% mortality rate at 30 days. Of those alive at 30 days, 94% of patients had successful limb salvage. Fifty-eight patients had complete follow-up data at 12 months. Of the patients alive at 12-month follow-up (75%), the limb salvage rate was 98%. Patients with amputation at 30 days had a significantly higher mortality rate at 12 months compared to those who did not (83% vs. 19%; P < 0.01). Based on MFI-11 scoring, 35% of the population was considered frail (≥0.27). Frail patients did not have significantly different 30-day outcomes (limb salvage: 94% vs. 88%; mortality 8% vs. 9%, P = 0.41 and 0.94, respectively) or 12-month outcomes (limb salvage: 82% vs. 94%; mortality: 32% vs. 22%, P = 0.28 and 0.39, respectively).

CONCLUSIONS

Endovascular procedures can be done safely in nonagenarians with low mortality and amputation rates. Patients with early amputation are at significantly higher risk of death at 12 months. Frailty, as measured by a validated index, was not associated with early or late outcomes. When compared to immediate amputation, nonagenarian patients and their families should be counseled as to the benefit from a minimally invasive endovascular procedure.

Comparative performance of three comorbidity scores in predicting survival after the elective repair of abdominal aortic aneurysms

BACKGROUND

We aimed to study the discriminative power of 3 comorbidity scores for predicting 5-year survival after the elective repair of aorto-iliac aneurysms (AAA).

METHODS

444 patients with AAA undergoing elective repair (33% open and 67% endovascular) between 2000 and 2020 were reviewed. The Charlson Comorbidity Index (CCI) and subsequent adjustments by Schneeweiss, Quan and Armitage, the Modified Frailty Index (MFI) and the American Society of Anesthesiologists Score (ASA) were calculated from preoperative data. Their association with 5-year survival was analyzed using Cox regression models and their discriminative power and its changes with C statistics and Net Reclassification Index (NRI).

RESULTS

All comorbidity scores were associated with survival after adjusting by age, sex and type of surgical repair: original CCI HR=1.24, P<0.001; Schneeweiss CCI HR=1.23, P<0.001; Quan CCI HR=1.27, P<0.001, Armitage CCI HR=1.46, P<0.001, MFI HR=1.39, P<0.001 and ASA HR=1.68 (P=0.04) and 2.86 (P=0.01) for classes III and IV, respectively. Associated C statistics were of 0.64, 0.65, 0.65, 0.64, 0.61 and 0.59, respectively. Compared with the original CCI, models based on Schneeweiss CCI and Armitage CCI provided minor improvements in NRI (0.32 and 0.23), and the model based on ASA showed lower C statistics (P=0.014) and NRI (-0.30).

CONCLUSIONS

Established comorbidity scores, such as CCI, MFI or ASA, are all associated with 5-year survival after the elective repair of AAAs, being ASA the worst of them. However, their predictive power is in no case sufficient to identify, by themselves, those patients who may not be eligible for intervention on the basis of life expectancy.

Frailty score and outcomes of patients undergoing vascular surgery and amputation: A systematic review and meta-analysis

Introduction

Frailty is associated with adverse postoperative health outcomes, including increased mortality, longer length of stay, higher rehospitalization, and other complications. There are many frailty assessment tools are to assess the level of frailty in vascular surgery patients. The aim of this study was to perform a systematic review and meta-analysis to assess the association between the frailty levels described by different frailty scores and adverse postoperative health outcomes among hospitalized vascular surgery patients and patients undergoing amputation.

Methods

Studies utilizing frailty scores and similar frailty assessment tools to describe frailty and investigate the association between frailty and health outcomes were searched. The primary outcomes of this study were in-hospital mortality, postdischarge mortality, length of hospital stay, rehospitalization, and discharge location. Additional outcomes included postoperative myocardial infarction, postoperative renal failure, cerebrovascular accident and stroke, comorbidities, and estimated glomerular filtration rate (eGFR) levels. Joanna Briggs Institute (JBI) Critical Appraisal Tools were used for quality assessment.

Results

In total, 24 studies with 1,886,611 participants were included in the final analysis. The overall results found that higher in-hospital mortality and postdischarge mortality were significantly associated with frailty. Frailty was also found to be significantly associated with a longer length of hospital stay, higher rehospitalization, and higher likelihood of non-home discharge. In addition, the results also showed that frailty was significantly associated with all kinds of comorbidities investigated, except chronic kidney disease. However, lower eGFR levels were significantly associated with frailty.

Conclusion

Among patients who underwent all types of vascular surgery and those who underwent amputations, assessment of frailty was significantly associated with adverse postoperative outcomes and multiple comorbidities.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=336374, identifier CRD42022336374.

Frailty predicts poor longer-term outcomes in patients following lower limb open surgical revascularization

BACKGROUND

Frailty in vascular surgery patients is increasingly recognized as a marker of poor outcome. This provides particular challenges for patients with lower limb peripheral arterial disease who require surgical revascularization. This study aimed to assess the impact of frailty on short- and long-term outcome in this specific patient group using a specialty specific frailty score.

METHODS

Patients undergoing open surgical revascularization for chronic limb ischemia (January 2015-December 2016) were assessed. Demographics, mode of admission, diagnosis, and site of surgery were recorded alongside a variety of frailty-specific characteristics. We calculated the previously validated Addenbrookes Vascular Frailty Score (AVFS) and Long AVFS (LAVFS). Primary outcome was 3-year mortality.

RESULTS

Two hundred and sixty-one patients (75% men, median age 69 years) were studied. The median length of stay was 6 days with a 3-year mortality of 23%. The predictive power of vascular frailty scores showed that for 3-year mortality, area under the receiver operator curve values (AUROC) were specific for both the AVFS score (AUROC: 0.724, 95% CI: 0.654-0.794) and LAVFS Score (AUROC: 0.741, 95%CI: 0.670-0.813). Furthermore, the cumulative AVFS and LAVFS scores both predicted mortality over the follow-up period (P=0.0001) with increased mortality among patients with higher scores.

CONCLUSIONS

Incremental worsening of frailty, determined using a specialty specific frailty score, predicts mortality risk in patients undergoing lower limb surgical revascularization.

Elevated Risk Analysis Index (RAI) Frailty Scores Are Independently Associated with Adverse Outcomes in Lower Extremity Surgical Revascularizations Similarly Across Genders

INTRODUCTION

The Risk Analysis Index (RAI) frailty scoring system, developed in a predominantly male Veteran sample, has recently undergone revision and external validation to become the RAI-rev using a general surgical sample from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. We set forth to evaluate the application of RAI-rev scoring to lower extremity surgical revascularization outcomes in the NSQIP database while verifying that similar associations with outcomes persist in this subset across genders.

METHODS

All elective cases in the NSQIP Targeted Lower Extremity Open (LEO) database recorded from 2015-2019 were paired with the NSQIP Participant User File using Case IDs. Groups were defined by EMR-recorded gender. Extended length of stay was defined as top quartile postoperative stays. Aggregate demographics, perioperative factors, and 30-day outcomes were compared between groups using unpaired t-test and Fisher's exact test. Adjusted odds-ratios (aOR) for each outcome were generated by applying a multivariate binary logistic regression model in IBM SPSS^TM for five-point RAI-rev score increments from 25-45 and a most-frail group with scores >45. Covariates included surgical indication, prior ipsilateral surgical revascularization versus percutaneous intervention, graft utilization, presence of dirty/infected wound, smoking, hypertension, diabetes, and steroid use. A non-frail group with RAI-rev scores <25 was utilized as the reference for generating adjusted odds ratios.

RESULTS

8,155 cases were recorded in the NSQIP LEO database from 2015-2019, including 2,498 (31%) performed in women who had slightly lower RAI-rev scores on average (22.1±5.8 vs 24.2±5.1; p=0.0001). Univariate trends demonstrated dose-dependent increases in frequency of most outcomes with rising frailty score ranges, with the most substantial changes over mortality (0.4% of non-frail to 14.7% most-frail), disposition to a skilled nursing facility (8% of non-frail to 27% most-frail), and extended length of stay (16% of non-frail to 44% most-frail). After adjusting for co-variates, patients with RAI-rev scores of 26-30 had aOR of 1.4 (95% CI: 1.2-1.6; p<0.001), 1.9 (95% CI: 1.6-2.2; p<0.001), and 2.4 (95% CI: 1.3-4.4; p<0.001) for extended stay, disposition to skilled nursing, and mortality respectively as compared to those with RAI-rev scores <25. Despite more non-significant aOR for women than men, trends were similar across genders in both univariate and multivariate analyses.

CONCLUSION

Our study is the first to find that outcomes other than mortality are significantly predicted by RAI-rev score ranges in lower extremity surgical revascularizations with similar associations regardless of gender. RAI-rev frailty scores >30 may help to identify frail patients at a higher risk of mortality, extended stay, and increased rehabilitation needs prior to lower extremity surgical revascularization to inform risk assessment and optimize patient recovery.

Frailty as a Predictor of Mortality for Fenestrated EVAR and Open Surgical Repair of Aortic Aneurysms Involving Visceral Vessels

OBJECTIVES

Frailty has been correlated with poor outcomes after major surgery across multiple specialties, but has not been studied in patients undergoing open or endovascular repair of suprarenal and thoracoabdominal aortic aneurysms. Fenestrated endovascular aneurysm repair (FEVAR) has emerged as a lower risk alternative to open surgical repair (OSR) for patients with complex aortic aneurysms involving the visceral artery branches. The objective of the current study was to examine the relationship between frailty and peri-operative outcomes for FEVAR and OSR in patients with suprarenal and thoracoabdominal aortic aneurysms.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent FEVAR or OSR for the years 2011 through 2017. Frailty was quantified using a modified 5-factor frailty index (mFI-5) that was previously validated for surgical patients. Frailty was correlated with the primary endpoint of 30-day mortality. Logistic regression was used to identify predictors of 30-day mortality.

RESULTS

A total of 675 FEVAR and 1,779 OSR operations were included in the analysis. The 30-day mortality rate was 3.0% for FEVAR and 7.1% for OSR (P = 0.002). Increasing frailty was significantly associated with higher 30-day mortality for both FEVAR (P = 0.018) and OSR (P = 0.0003). Independent predictors of 30-day mortality were frailty score (Odds Ratio [OR] 1.22 [per 0.1-unit increase]; P = 0.0005), type of repair (OSR versus FEVAR, OR 2.46; P = 0.0001), age (OR 1.03; P = 0.0025), female sex (OR 1.61; P = 0.007), Hispanic ethnicity (OR 2.68; P = 0.021), American Society of Anesthesiology [ASA] class (OR 1.57; P = 0.035), preoperative dialysis (OR 3.45; P = 0.032), and history of bleeding disorder (OR 2.60; P < 0.0001).

CONCLUSIONS

Frailty, as measured using a mFI-5 score, is an independent predictor of 30-day mortality, overall complications, and length of stay after FEVAR or OSR. Frailty should be used to identify patients at high risk of adverse postoperative outcomes to determine if this risk is modifiable or whether nonoperative is the most appropriate option. FEVAR may offer improved 30-day outcomes, compared to OSR, for the frailest patients.

The influence of frailty on postoperative complications in geriatric patients receiving single-level lumbar fusion surgery

PURPOSE

This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery.

METHODS

The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios.

RESULTS

Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals.

CONCLUSIONS

Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.

Associations of Clinical Frailty with Severity of Limb Threat and Outcomes in Chronic Limb-threatening Ischaemia

OBJECTIVE

Investigate the relationship of frailty and severity of chronic limb-threatening ischaemia (CLTI), and their comparative associations with one-year outcomes, in patients presenting to a vascular limb salvage (VaLS) clinic.

METHODS

This retrospective cohort study utilised data collected from a prospectively maintained VaLS clinic database. Patients aged ≥50 presenting to the VaLS clinic with CLTI between February 2018 and April 2019 were included. Frailty was measured using the Clinical Frailty Scale (CFS) and limb threat severity by the Wound, Ischaemia, and foot Infection (WIfI) score. Excessive polypharmacy was defined as ≥10 medications. Anticholinergic burden (ACB) score and Charlson comorbidity index (CCI) were calculated for all patients. The primary outcome measure was a composite endpoint of death or amputation at one-year. Associations with outcome were assessed using Cox regression and reported as hazards ratios (HR) with 95% confidence intervals (CI).

RESULTS

A total of 198 patients were included, with CFS scores available for 190 patients. 98 patients (52%) were frail (CFS ≥5). 127 patients (67%) initially underwent endovascular revascularisation. Excessive polypharmacy was common (55 patients; 28%). Frailty was associated with increased WIfI stage (P = 0.025) as well as age, female sex, CCI score, number of medications, excessive polypharmacy but not ACB score. Frail patients were more frequently managed non-operatively (P = 0.017). Frailty (HR 1.91; 95% CI 1.09, 3.34; P = 0.024) and WIfI stage 4 (HR 3.29; 95%CI 1.23, 8.80; P = 0.018) were associated with death or amputation on univariable analysis. WIfI stage 4 (HR 2.80; 95%CI 1.04, 7.57; P = 0.042) and CCI score (HR 1.21; 95%CI 1.03, 1.41; P = 0.015), but not frailty (HR 1.25; 95%CI 0.67, 2.33; P = 0.474), were independently associated with death or amputation on multivariable analysis.

CONCLUSIONS

Frailty is highly prevalent among CLTI patients and related to severity of limb threat. The CFS may be a useful adjunct to patient risk assessment in CLTI.

Sarcopenia in Patients Undergoing Lower Limb Bypass Surgery is Associated with Higher Mortality and Major Amputation Rates

BACKGROUND

Sarcopenia is adversely associated with survival in several diseases. Vasculopathy is often associated with multimorbidity and consequent deconditioning with poor long-term outcomes. This study examined the impact of sarcopenia on clinical outcome in patients with and without critical limb-threatening ischaemia who underwent infrainguinal bypass surgery.

METHODS

All patients undergoing infra-inguinal surgical revascularisation in 2016-2018 were retrospectively reviewed. Sarcopenia was defined as a skeletal muscle area at the L3 vertebral level (defined as L3 muscle area < 114cm² for men or <89.8cm² for women) on CT angiography. The primary outcome was overall survival by analysed by time to event analysis. Secondary outcomes included ipsilateral major lower-limb amputation, length of hospital stay, myocardial infarction and surgical-site infection.

RESULTS

A total of 116 patients with a mean age of 66.9 years were included, with a mean follow-up of 21 months. 14 (12%) of patients were sarcopenic; there were more patients with diabetes (40% vs 7%) in the sarcopenic group, p=0.018. Age, gender, Rutherford grade at presentation, other co-morbidities, other laboratory tests, conduit material and Rutherford grade at presentation were similar in those with and without sarcopenia and were statistically insignificant upon testing. Overall survival was worse for sarcopenic patients (Log Rank P=0.001) and Hazard Ratio for death 5.8; 95%CI 1.8-19.1; P=0.001. Major lower-limb amputation occurred more frequently in patients with sarcopenia (7/14 [50%] vs 23/102 [23%]; P=0.046). There was no difference in other secondary outcomes including rates of graft occlusion, myocardial infarction, surgical site infection and length of stay. Adding SMA measurement to a multivariate generalised linear model including age, sex, diabetes, and haemoglobin improved the AUROC from 0.75-0.85.

CONCLUSION

In this cohort of patients undergoing vascular surgery, sarcopenia defined using L3 muscle area was significantly associated with overall mortality and major lower-limb amputation.

Frailty as a predictor of major adverse cardiac and cerebrovascular events after endovascular aortic aneurysm repair

OBJECTIVE

To evaluate the effect of frailty assessed by the modified Frailty Index (mFI) on major adverse cardiac and cerebrovascular events (MACCE) in the elderly patients after endovascular aortic aneurysm repair (EVAR).

METHODS

This was a retrospective cohort study of elderly patients who underwent EVAR in a tertiary hospital. The main exposure was frailty status assessed by the mFI. The primary outcomes were 30-day and long-term MACCE. The predictive ability of the mFI was compared with the Revised Cardiac Risk Index (RCRI) using net reclassification improvement (NRI) and integrated discrimination improvement (IDI) statistics.

RESULTS

Of 749 participants, 134 (17.89%) were identified as frail and 185 (24.70%) as prefrail. Thirteen patients (1.74%) were lost in follow-up after surgery, and the median length of follow-up was 32.00 months (range, 15.00-59.25 months). Frailty was associated with a significantly increased risk of 30-day MACCE (adjusted odds ratio OR, 14.53; 95% confidence interval [CI], 4.59-46.04; P < .0001) and longer intensive care unit stay (adjusted odds ratio, 2.43; 95% CI, 1.17-5.07; P = .0176). As for long-term outcomes, both frailty and prefrailty were associated significantly increased risks of MACCE after EVAR (prefrail: adjusted hazard ratio [HR] 1.71; 95% CI, 1.12-2.61; frail: adjusted HR, 3.37; 95% CI, 1.86-6.10). When considering death as a competing risk, we also observed a significant association between frailty and cardiac and cerebrovascular events (adjusted HR, 2.95; 95% CI, 1.06-8.15). In addition, frailty was associated with a significantly increased risk of all-cause mortality (adjusted HR, 1.93; 95% CI, 1.28-2.90). Compared with the RCRI, the mFI had better discrimination in predicting 30-day MACCE (IDI: 0.225; 95% CI, 0.018-0.431; P = .033; NRI: 0.225; 95% CI, 0.023-0.427; P = .029) and long-term MACCE (IDI: 0.056; 95% CI, 0.018-0.128; P = .013; NRI: 0.237; 95% CI, 0.136-0.359; P < .001).

CONCLUSIONS

Frailty assessed by the mFI may serve as a useful predictor of both short-term and long-term MACCE in elderly patients after EVAR, with improved discrimination and reclassification abilities compared with the RCRI.

The modified frailty index-11 predicts medium-term outcomes after endovascular revascularisation for chronic limb threatening ischaemia in Asian patients

OBJECTIVE

The aim was to evaluate the utility of frailty, as defined by the modified Frailty Index-1 1 (mFI-11) on predicting outcomes following endovascular revascularisation in Asian patients with chronic limb-threatening ischaemia (CLTI).

METHODS

CLTI patients who underwent endovascular revascularisation between January 2015 and March 2017 were included. Patients were retrospectively scored using the mFI-11 to categorise frailty as low, medium or high risk. Observed outcomes included 30-day complication rate and unplanned readmissions, 1-, 6- and 12-month mortality, and ambulation status at 6- and 12 months post-intervention.

RESULTS

A total of 233 patients (250 procedures) were included; 137 (58.8%) were males and the mean age was 69.0 (±10.7) years. 202/233 (86.7%) were diabetic and 196/233 (84.1%) had a prior diagnosis of peripheral arterial disease (PAD). The mean mFI-11 score was 4.2 (±1.5). 28/233 (12.0%), 155/233 (66.5%), and 50/233 (21.5%) patients were deemed low (mF-11 score 0-2), moderate (mFI-11 score 3-5) and high (mFI-11 score 5-7) frailty risk, respectively. High frailty was associated with an increased 12-month mortality (OR 8.54, 95% CI 1.05-69.5; p = 0.05), 30-day complication rate (OR 9.41, 95% CI 2.01-44.1; p < 0.01) and 30-day unplanned readmission (OR 5.06, 95% CI 1.06-24.2; p = 0.04). Furthermore, a high score was associated with a significantly worse 6- (OR 0.320, 95% CI 0.120-0.840; p = 0.02) and 12-month (OR 0.270, 95% CI 0.100-0.710; p < 0.01) ambulatory status.

CONCLUSION

The mFI-11 is a useful, non-invasive tool that can be readily calculated using readily available patient data, for prediction of medium-term outcomes for Asian CLTI patients following endovascular revascularisation. Early recognition of short- and mid-term loss of ambulation status amongst high-frailty patients in this challenging cohort of patients could aid decision-making for whether a revascularisation or amputation-first policy is appropriate, and manage patient and caregiver expectations on potential improvement in functional outcome.

Wound location is independently associated with adverse outcomes following first-time revascularization for tissue loss

OBJECTIVE

Few studies adequately evaluate the impact of wound location on patient outcomes after lower extremity revascularization. Consequently, we evaluated the relationship between lower extremity wound location and long-term outcomes.

METHODS

We reviewed all patients at our institution undergoing any first-time open surgical bypass or percutaneous transluminal angioplasty with or without stenting for tissue loss between 2005 and 2014. We categorized wounds into three distinct groups: forefoot (ie, toes and metatarsal heads), midfoot (ie, dorsal, plantar, lateral, medial surfaces excluding toes, metatarsal heads, or heel), and heel. Limbs with multiple wounds were excluded from analyses. We compared rates of perioperative complications, wound healing, reintervention, limb salvage, amputation-free survival, and survival using χ², Kaplan-Meier, and Cox regression analyses.

RESULTS

Of 2869 infrainguinal revascularizations from 2005 to 2014, 1126 underwent a first-time revascularization for tissue loss, of which 253 patients had multiple wounds, 197 had wounds proximal to the ankle, 100 had unreliable wound information, and 576 (forefoot, n = 397; midfoot, n = 61; heel, n = 118) fit our criteria and had a single foot wound with reliable information regarding wound specifics. Patients with forefoot, midfoot, and heel wounds had similar rates of coronary artery disease, hypertension, diabetes, and smoking history (all P > .05). Conversely, there were significant differences in patient age (71 vs 69 vs 70 years), prevalence of gangrene (41% vs 5% vs 21%), and dialysis dependence (18% vs 17% vs 30%) (all P < .05). There were no statistically significant differences in perioperative mortality (1.3% vs 4.9% vs 4.2%; P = .06) or postoperative complications among the three groups. Between forefoot, midfoot, and heel wounds, there were significant differences in unadjusted 6-month rates of complete wound healing (69% vs 64% vs 53%), 3-year rates of amputation-free survival (54% vs 57% vs 35%), and survival (61% vs 72% vs 41%) (all P < .05). After adjustment, compared with forefoot wounds, heel wounds were associated with higher rates of incomplete 6-month wound healing (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.]), major amputation or mortality (HR, 1.7; 95% CI, 1.1-2.7), and all-cause mortality (HR, 1.8; 95% CI, 1.1-3.0), but not major amputation alone (HR, 2.1; 95% CI, 0.9-4.5). In open surgical bypass-first patients, heel wounds were solely associated with an increased risk of all-cause mortality (HR, 1.7; 95% CI, 1.1-2.8), whereas heel wounds in percutaneous transluminal angioplasty-first patients were associated with an increased risk of incomplete wound healing (HR, 2.2; 95% CI, 1.3-3.7), major amputation or mortality (HR, 2.3; 95% CI, 1.1-5.4), and all-cause mortality (HR, 2.8; 95% CI, 1.1-7.2).

CONCLUSIONS

Heel wounds confer considerably higher short- and long-term morbidity and mortality compared with midfoot or forefoot wounds in patients undergoing any first-time lower extremity revascularization.