Effect of sarcopenia on survival and spinal cord deficit outcomes after thoracoabdominal aortic aneurysm repair in patients 60 years of age and older

Computed tomography -defined sarcopenia is associated with long-term survival among patients undergoing open thoracic aortic reconstruction

BACKGROUND AND OBJECTIVE

As markers of sarcopenia, psoas muscle areas and indexes measured from computed tomography images have been found to predict long-term mortality in cardiothoracic as well as other surgical cohorts. Our objective was to investigate the association between psoas muscle status, taking into account muscle density in addition to area, and survival among patients undergoing open thoracic aortic reconstruction.

METHODS

This was a retrospective registry study of a total of 451 patients treated with open surgery for thoracic aortic pathology. Psoas muscle area and density were measured from preoperative computed tomography images at the L3 and L4 lumbar levels. In addition, lean psoas muscle area was calculated by averaging sex-specific values of psoas muscle area and density. The association between mortality and psoas muscle status was analyzed with adjusted Cox-regression analysis.

RESULTS

The median age of the study population was 63 (interquartile range (IQR): 53-70) years. The majority were male (74.7%, n = 337) and underwent elective procedures (58.1% n = 262). Surgery of the ascending aorta was carried out in 90% of the patients, and 15% (n = 67) had concomitant coronary artery bypass surgery. Aortic dissection was present in 34.6% (n = 156) patients. Median follow-up time was 4.3 years (IQR: 2.2-7.4). During the follow-up, 106 patients (23.5%) died, with 55.7% of deaths occurring within the first four postoperative weeks. Psoas muscle parameters were not associated with perioperative mortality, but significant independent associations with long-term mortality were observed for psoas muscle area, density, and lean psoas muscle area with hazard ratios (HRs) of 0.63 (95% confidence interval (CI): 0.45-0.88), 0.62 (95% CI: 0.46-0.83), and 0.47 (95% CI: 0.32-0.69), respectively (all per 1-SD increase).

CONCLUSIONS

Psoas muscle sarcopenia status is associated with long-term mortality after open thoracic aortic surgery.

The Impact of Sarcopenia in the Long-Term Survival of Patients following Complex Endovascular Aortic Surgery for Thoracoabdominal Aortic Aneurysms

OBJECTIVES

Image-based sarcopenia has been the subject of recent studies, hypothesized as a prognostic factor for patients with thoracoabdominal aortic aneurysms.

METHODS AND MATERIALS

We conducted a single-center retrospective analysis of patients who underwent complex endovascular repair for thoracoabdominal aortic aneurysms between 2008 and 2016. CT image assessment was performed and patients were classified as sarcopenic and non-sarcopenic using two stratification methods: skeletal mass index (SMI) and total psoas muscle index (TPMI). According to sex, each patient was defined as sarcopenic if their SMI or TPMI was in the lowest third of the study group. The primary endpoint was impact of sarcopenia on perioperative mortality and long-term survival. Secondary endpoints were perioperative complications.

RESULTS

From a total of 155 patients, 135 were eligible for study. Overall, in-hospital mortality was 5.9% (8/135). The 30-day, 1-year, 3-year and 5-year mortality was 10.4% (14/135), 20% (27/135), 28.1% (38/135) and 31.1% (42/135), respectively. There was no difference in the long-term mortality rates between sarcopenic and non-sarcopenic patients regardless of the stratification method used (p = 0.4 for SMI and p = 0.2 for TPMI). According to SMI, 30-day mortality of sarcopenic patients was significantly lower in comparison to non-sarcopenic patients (1/45, 2.2% vs. 13/90, 14.4%, p = 0.028). Based on the total psoas muscle index, sarcopenic patients were at higher risk for development of pulmonary complications in comparison to non-sarcopenic patients postoperatively (p = 0.03).

CONCLUSION

Using SMI and TPMI, sarcopenia was not associated with reduced long-term survival in patients undergoing complex endovascular repair for thoracoabdominal aortic aneurysms.

Smaller rectus femoris size measured by ultrasound is associated with poorer outcomes after cardiac surgery

OBJECTIVE

We sought to evaluate the association of low rectus femoris cross-sectional area (RFCSA) with hospital length of stay and poorer outcomes in patients undergoing cardiac surgery.

METHODS

A single right-leg RFCSA was measured with ultrasound preoperatively and baseline characteristics, clinical data, and outcomes recorded. Patients were categorized as low rectus femoris muscle size (lowRF) or normal rectus femoris muscle size (normalRF), if they were in the lowest quartile or not, respectively. All analyses were performed on both body surface area (BSA)- and sex-adjusted RFCSA.

RESULTS

One hundred eight-four patients had a RFCSA measured with a mean of 5.01 cm2 (1.41 cm2), and range of 0.71 to 8.77 cm2. When analyzing the BSA-adjusted RFCSA, we found the lowRF group had a longer hospital stay, 11.0 days [7.0-16.3] versus 8.0 days [6.0-10.0] for the normalRF group (P < .001), and a greater proportion of extended hospital stay (≥18.5 days) of 19.6% compared with 6.2% (P = .010). When the RFCSA was adjusted for sex, the lowRF group had a greater length of hospital stay, 9.0 days [7.0-14.5] versus 8.0 days [6.0-11.0] (P = .049). In both the BSA- and sex-adjusted RFCSA, the lowRF group suffered greater morbidity and were more likely discharged to a destination other than home. In multivariate analyses adjusting for European System for Cardiac Operative Risk Evaluation II, BSA-adjusted lowRF but not sex-adjusted lowRF was independently associated with log-transformed hospital length of stay. LowRF was not independently associated with increased major morbidity and death for both BSA and sex-adjusted RFCSA.

CONCLUSIONS

Low RFCSA has a significant association with increased hospital length of stay, morbidity, and nonhome discharge in patients undergoing cardiac procedures.

TRIAL REGISTRY NUMBER

ACTRN12620000678998.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

BACKGROUND

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

METHODS

The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

RESULTS

A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

CONCLUSION

Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Effect of Sarcopenia on Mortality and Spinal Cord Ischaemia After Complex Aortic Aneurysm Repair: Systematic Review and Meta-Analysis

OBJECTIVE

Sarcopenia has been related to higher mortality rates after abdominal aortic aneurysm repair. This analysis aimed to assess sarcopenia related mortality and spinal cord ischaemia (SCI) at 30 days, and mortality during the available follow up, in patients with complex aortic aneurysms, managed with open or endovascular interventions.

DATA SOURCES

A search of the English literature, via Ovid, using Medline, EMBASE, and CENTRAL up to 15 June 2022 was done.

REVIEW METHODS

This meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and preregistered in PROSPERO (CRD42022338079). Observational studies (2000 - 2022), with five or more patients, reporting on sarcopenia related mortality and SCI at 30 days, and midterm mortality after thoraco-abdominal aneurysm repair (open or endovascular), were eligible. The ROBINS-I tool (Risk Of Bias In Non-Randomised Studies of Interventions) was used for risk of bias, and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) for the assessment of evidence quality. The primary outcome was 30 day and midterm mortality, and the secondary outcome was SCI at 30 days, in sarcopenic and non-sarcopenic patients. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Four retrospective studies (1 092 patients; 40.0% sarcopenic) were included. Thirty day mortality was similar, with low certainty between groups (6% [95% CI 1 - 11] in sarcopenic vs. 5% [95% CI 1 - 9] non-sarcopenic patients [OR 0.30, 95% CI -0.21 - 0.81; p = .94, Ι2 = 0%). The estimated midterm mortality was statistically significantly higher (very low certainty) in sarcopenic patients (25% [95% CI 0.19 - 0.31] vs. 13% [95% CI -0.03 - 0.29] in non-sarcopenic patients (1.11 OR 0.95, 95% CI -0.21 - 2.44; p < .001, Ι2 = 88.32%). SCI was significantly higher (very low certainty) in sarcopenic patients (19%, 95% CI 4 - 34) vs. 7% (95% CI 5 - 20) in non-sarcopenic patients (OR 1.80, 95% CI -0.17 - 3.78; Ι2 = 82.4%), despite an equal distribution of aneurysm type between the groups.

CONCLUSION

Early mortality does not appear to be affected by sarcopenia in patients treated for thoraco-abdominal aneurysms. However, sarcopenia may be associated with higher peri-operative SCI and midterm mortality rates.

Utility of psoas muscle area in selecting older patients feasible for thoracic endovascular aortic repair

BACKGROUND

The impact of psoas muscle mass index (PMI) on overall survival is unknown in older patients undergoing elective thoracic endovascular aortic repair (TEVAR).

METHODS

We retrospectively reviewed 105 patients 75 years and older who underwent elective TEVAR for descending thoracic aortic aneurysm between January 2010 and December 2019. Psoas muscle area was measured at the L3 level with preoperative computed tomography and adjusted by height² to derive PMI. The patients were stratified into two groups, Sarcopenia and Non-sarcopenia. Sarcopenia was defined as a PMI < 5.40 cm²/m² for male and < 3.56 cm²/m² for female. The overall survival was compared with the age- and sex-matched general population using the one-sample log-rank test. The propensity score adjusted-Cox proportional-hazard model was applied to determine the hazard ratio for all-cause mortality.

RESULTS

Twenty-three patients died during the follow-up period (median, 3.0 years). Thirty-eight (36%) patients were classified as Sarcopenia. The 5-year overall survival rate was 46% (95% confidence interval, 29-73) in Sarcopenia and 84% (95% confidence interval, 74-94) in Non-sarcopenia. The overall survival was significantly lower in Sarcopenia than in its matched general population (P = .004). Whereas, no statistically significant difference in overall survival was found between Non-sarcopenia and its matched general population (P = .417). Sarcopenia was an independent risk factor for all-cause mortality (adjusted hazard ratio, 2.64; 95% confidence interval, 1.02- 6.82; P = .045).

CONCLUSIONS

PMI may be a good predictor of mortality in older patients undergoing elective TEVAR for descending thoracic aortic aneurysm.

Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA). Currently, open surgical repair has been reserved mostly for young and fit patients with connective tissue disorders, using separate branch vessel reconstructions instead of 'island' patches, and distal perfusion instead of a 'clamp and go' technique. Endovascular repair has gained widespread acceptance because of its potential to significantly decrease morbidity and mortality. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular aortic repair (FB-EVAR) using patient-specific and off-the-shelf devices, which offers a less-invasive alternative to open repair. Although FB-EVAR was initially considered an option for older and frail patients, many centers have expanded its indications to any patient with suitable anatomy and no evidence of connective tissue disorders, independent of their clinical risk. In this article, we review current techniques and outcomes of endovascular TAAA repair.

Are Sarcopenia and Myosteatosis in Elderly Patients with Pelvic Ring Injury Related to Mortality, Physical Functioning and Quality of Life?

The purpose of this study was to evaluate the prevalence of sarcopenia and/or myosteatosis in elderly patients with pelvic ring injuries and their influence on mortality, patient-perceived physical functioning and quality of life (QoL). A multicenter retrospective cohort study was conducted including elderly patients aged ≥ 65 treated for a pelvic ring injury. Cross-sectional computed tomography (CT) muscle measurements were obtained to determine the presence of sarcopenia and/or myosteatosis. Kaplan–Meier analysis was used for survival analysis, and Cox proportional hazards regression analysis was used to determine risk factors for mortality. Patient-reported outcome measures for physical functioning (SMFA) and QoL (EQ-5D) were used. Multivariable linear regression analyses were used to determine the effect of sarcopenia and myosteatosis on patient-perceived physical functioning and QoL. Data to determine sarcopenia and myosteatosis were available for 199 patients, with a mean follow-up of 2.4 ± 2.2 years: 66 patients (33%) were diagnosed with sarcopenia and 65 (32%) with myosteatosis, while 30 of them (15%) had both. Mortality rates in patients at 1 and 3 years without sarcopenia and myosteatosis were 13% and 21%, compared to 11% and 36% in patients with sarcopenia, 17% and 31% in patients with myosteatosis and 27% and 43% in patients with both. Higher age at the time of injury and a higher Charlson Comorbidity Index (CCI) were independent risk factors for mortality. Patient-reported mental and emotional problems were significantly increased in patients with sarcopenia.