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Welsh SA, Pearson RC, Hussey K, Brittenden J, Orr DJ, Quinn T. A systematic review of frailty assessment tools used in vascular surgery research. J Vasc Surg 2023; 78:1567-1579.e14. [PMID: 37343731 DOI: 10.1016/j.jvs.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/23/2023]
Abstract
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.
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Affiliation(s)
- Silje A Welsh
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland.
| | - Rebecca C Pearson
- Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, Scotland
| | - Keith Hussey
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Julie Brittenden
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Douglas J Orr
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Terry Quinn
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland
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2
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Cardiel-Pérez A, Paredes-Mariñas E, Nieto-Fernández L, Abadal-Jou M, Mellado-Joan M, Clarà-Velasco A. Comparative performance of three comorbidity scores in predicting survival after the elective repair of abdominal aortic aneurysms. INT ANGIOL 2023; 42:73-79. [PMID: 36744425 DOI: 10.23736/s0392-9590.22.04974-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Ada Cardiel-Pérez
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain
| | - Ezequiel Paredes-Mariñas
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain - .,Department of Surgery, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Mar Abadal-Jou
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain
| | | | - Albert Clarà-Velasco
- Department of Vascular and Endovascular Surgery, Hospital del Mar, Barcelona, Spain.,CIBER Cardiovascular, Institut Hospital del Mar d'Investigacions Mèdiques, Hospital del Mar, Barcelona, Spain.,Department of Medicine and Surgery, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain
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3
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Kalyanasundaram A, Choy M, Kotta A, Zielinski LP, Coughlin PA. Frailty predicts poor longer-term outcomes in patients following lower limb open surgical revascularization. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:716-723. [PMID: 36168946 DOI: 10.23736/s0021-9509.22.11895-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
| | - Matthew Choy
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alekhya Kotta
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lukasz P Zielinski
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick A Coughlin
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK -
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4
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Koh BJ, Lee Q, Wee IJ, Syn N, Lee KS, Jie Ng J, Wong ALA, Soong JT, Mtl Choong A. Frailty scoring in vascular and endovascular surgery: A systematic review. Vasc Med 2022; 27:302-307. [PMID: 35681271 DOI: 10.1177/1358863x221093400] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
One in 10 independently living adults aged 65 years old and older is considered frail, and frailty is associated with poor postoperative outcomes. This systematic review aimed to examine the association between frailty assessments and postoperative outcomes in patients with vascular disease. Electronic databases - MEDLINE, Embase, and the Cochrane Library - were searched from inception until January 2022, resulting in 648 articles reviewed for potential inclusion and 16 studies selected. Demographic data, surgery type, frailty measure, and postoperative outcomes predicted by frailty were extracted from the selected studies. The risk of bias was assessed using the Newcastle-Ottawa Scale. The selected studies (mean age: 56.1-76.3 years) had low-to-moderate risk of bias and included 16 vascular (elective and nonelective) surgeries and eight frailty measures. Significant associations (p < 0.05) were established between mortality (30-day, 90-day, 1-year, 5-year), 30-day morbidity, nonhome discharge, adverse events, failure to rescue, patient requiring care after discharge, and amputation following critical limb ischaemia. The strongest evidence was found between 30-day mortality and frailty. Composite 30-day morbidity and mortality, functional status at discharge, length of stay, spinal cord deficit, and access site complications were found to be nonsignificantly associated with frailty. With frailty being significantly associated with several adverse postoperative outcomes, preoperative frailty assessments can potentially be clinically useful in helping practitioners predict and guide the pre-, peri-, and postoperative management of frail with vascular disease.
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Affiliation(s)
- Bernard Jqw Koh
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Quinncy Lee
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Faculty of Health Sciences, University of Hull, Kingston upon Hull, UK.,The Institute of Applied Health Sciences, The School of Medicine, Medical Sciences, and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Ian Jy Wee
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Syn
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Keng Siang Lee
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Jun Jie Ng
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Vascular and Endovascular Surgery, National University Heart Centre Singapore, Singapore
| | - Audrey LA Wong
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Division of Advanced Internal Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - John Ty Soong
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Division of Advanced Internal Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Mtl Choong
- SingVaSC, Singapore Vascular Collaborative, Singapore.,Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Vascular and Endovascular Surgery, National University Heart Centre Singapore, Singapore
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5
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Brown K, Cheng Y, Harley S, Allen C, Claridge M, Adam D, Lord JM, Nasr H, Juszczak M. Association of SARC-F Score and Rockwood Clinical Frailty Scale with CT-Derived Muscle Mass in Patients with Aortic Aneurysms. J Nutr Health Aging 2022; 26:792-798. [PMID: 35934824 DOI: 10.1007/s12603-022-1828-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Patients with aortic aneurysms (AA) are often co-morbid and susceptible to frailty. Low core muscle mass has been used as a surrogate marker of sarcopenia and indicator of frailty. This study aimed to assess association between core muscle mass with sarcopenia screening tool SARC-F and Clinical Frailty Scale (CFS) in patients with AA. METHODS Prospective audit of patients in pre-operative aortic clinic between 01/07/2019-31/01/2020 including frailty assessment using Rockwood CFS and sarcopenia screening using SARC-F questionnaire. Psoas and sartorius muscle area were measured on pre-operative CT scans and adjusted for height. Association was assessed using Spearman's rank correlation coefficient. RESULTS Of 84 patients assessed, median age was 75 years [72,82], 84.5% were men, 65.5% were multimorbid and 63.1% had polypharmacy. Nineteen percent were identified as frail (CFS score >3) and 6.1% positively screened for sarcopenia (SARC-F score 4 or more). Median psoas area (PMA) at L3 was 5.6cm2/m2 [4.8,6.6] and L4 was 7.4cm2/m2 [6.3,8.6]. Median sartorius area (SMA) was 1.8 cm2/m2 [1.5,2.2]. CFS demonstrated weak but statistically significant negative correlation with height-adjusted PMA at L3 (r=-0.25, p=0.034) but not at L4 (r=-0.23, p=0.051) or with SMA (r=-0.22, p=0.065). No association was observed between SARC-F score and PMA or SMA (L3 PMA r=-0.015, p=0.9; L4 PMA r=-0.0014, p= 0.99; SMA r=-0.051, p=0.67). CONCLUSION CFS showed higher association with CT-derived muscle mass than SARC-F. Comprehensive pre-operative risk-stratification tools which incorporate frailty assessment and body composition analysis may assist in decision making for surgery and allow opportunity for pre-habilitation.
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Affiliation(s)
- K Brown
- Kathryn Brown MBChB, Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, United Kingdom,
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6
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Furukawa H. Current Clinical Implications of Frailty and Sarcopenia in Vascular Surgery: A Comprehensive Review of the Literature and Consideration of Perioperative Management. Ann Vasc Dis 2022; 15:165-174. [PMID: 36310738 PMCID: PMC9558142 DOI: 10.3400/avd.ra.22-00035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/15/2022] [Indexed: 11/27/2022] Open
Abstract
Frailty is a well-known geriatric syndrome of impaired physiological reserve and increased vulnerability to stressors. Sarcopenia is also used as a parameter of physical impairment characterized by muscle weakness. As population aging has become more prominent in recent years, both modalities are now regarded as clinically important prognostic tools defined by multidimensional factors that may affect clinical outcomes in various clinical settings. A preoperative surgical risk analysis is mandatory to predict clinical and surgical outcomes in all surgical practices, particularly in high-risk surgical patients. In vascular surgical settings, frailty and sarcopenia have been accepted as useful prognostic tools to evaluate patient characteristics before surgery, as these may predict perioperative clinical and surgical outcomes. Although minimally invasive surgical approaches, such as endovascular therapy, and hybrid approaches have been universally developed, achieving good vascular surgical outcomes for high-risk cohorts remains to be challenge due to the increasing prevalence of elderly patients and multiple preoperative co-morbidities in addition to frailty and sarcopenia. Therefore, to further improve clinical and surgical outcomes, these preoperative geriatric prognostic factors will be of great importance and interest in vascular surgical settings for both physicians and surgeons.
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Affiliation(s)
- Hiroshi Furukawa
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University Adachi Medical Center
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7
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Rao A, Mehta A, Lazar AN, Siracuse J, Garg K, Schermerhorn M, Takayama H, Patel VI. The Association Between Preoperative Independent Ambulatory Status and Outcomes After Open Abdominal Aortic Aneurysm Repairs. Ann Vasc Surg 2021; 81:70-78. [PMID: 34785339 DOI: 10.1016/j.avsg.2021.10.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Preoperative functional status is appreciated as a key determinant of decision-making when evaluating patients for complex elective surgeries. We used the Vascular Quality Initiative (VQI) to analyze the effect of being able to independently ambulate on outcomes after open abdominal aortic aneurysm (AAA) repairs. METHODS We identified all patients who underwent elective or urgent open AAA repairs from January 2013 to August 2019 in the VQI registry. We recorded demographic variables, comorbidities, and operative factors such as approach, operative ischemia time, proximal clamp site, and presence of iliac aneurysms. Short-term and long-term outcomes included 30-day mortality, any perioperative complications, failure to rescue (defined as death after a complication), and one-year all-cause mortality. We dichotomized patients based on their ability to independently ambulate (Ambulatory) or inability to ambulate independently (Non-Ambulatory) and used both multivariable logistic regressions and cox-proportional hazards models to evaluate outcomes. RESULTS Of 5,371 patients, 328 (6.1%) could not ambulate independently and were more likely to be older (median age 69 vs 72), female (25% vs. 38%), and have greater comorbidities. Overall outcomes were: 4.3% for 30-day mortality, 38.7% for complications, 10.2% for failure-to-rescue, and 6.9% for one-year mortality. Univariate analysis showed higher rates of all adverse outcomes in non-ambulatory patients. On adjusted analysis, non-ambulatory patients had increased odds of complications by 46% (OR 1.46 [95%-CI 1.11-1.91]) and one-year mortality by 46% (HR 1.46 [95%-CI 1.06-1.99]), but not failure to rescue (OR 1.05 [95%-CI 0.67-1.62]) or 30-day mortality (OR 1.22 [95%-CI 0.82-1.81]). Increased hospital volume, age, and increased operative renal ischemia time were independently associated with adverse outcomes. CONCLUSIONS Non-ambulatory status was observed in a small percentage of patients undergoing open AAA repair but was associated with higher rates of post-operative complications and one-year mortality. Ambulatory capacity is one of the key determinants of outcomes following open AAA repair. In patients with poor ambulatory function, a conservative approach is highly recommended over invasive open surgical intervention.
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Affiliation(s)
- Abhishek Rao
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA)
| | - Ambar Mehta
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA)
| | - Andrew N Lazar
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA).
| | - Jeffrey Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, 732 Harrison Avenue, 3(rd) Floor, Boston, MA, 02118 (USA)
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University, 530 1(st) Avenue, 11(th) Floor, New York, NY, 10016 (USA)
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, STE 5B, Boston, MA, 02215 (USA)
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA)
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032 (USA)
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Mudge AM, McRae P, Donovan PJ, Reade MC. Multidisciplinary quality improvement programme for older patients admitted to a vascular surgery ward .. Intern Med J 2021; 50:741-748. [PMID: 32537917 DOI: 10.1111/imj.14400] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Older vascular surgical patients are at high risk of hospital-associated complications and prolonged stays. AIMS To implement a multidisciplinary co-management model for older vascular patients and evaluate impact on length of stay (LOS), delirium incidence, functional decline, medical complications and discharge destination. METHODS Prospective pre-post evaluation of a quality improvement intervention, enrolling pre-intervention (August 2012-January 2013) and post-intervention cohort (September 2013-March 2014). Participants were consenting patients aged 65 years and over admitted to the vascular surgical ward of a metropolitan teaching hospital for at least 3 days. Intervention was physician-led co-management plus a multidisciplinary improvement programme targeting delirium and functional decline. Primary outcomes were LOS, delirium and functional decline. Secondary outcomes were medical complications and discharge destination. Process measures included documented consultation patterns. Administrative data were also compared for all patients aged 65 and older for 12 months pre- and post-intervention. RESULTS We enrolled 112 participants pre-intervention and 123 participants post-intervention. LOS was reduced post-intervention (geometric mean 7.6 days vs 9.3 days; ratio of geometric means 0.82 (95% confidence interval CI0.68-1.00), P = 0.04). There was a trend to less delirium (18 (14.6%) vs 24 (21.4%), P = 0.17) and functional decline (18 (14.6%) vs 27 (24.3%), P = 0.06), with greatest reductions in the urgently admitted subgroup. Administrative data showed reduced median LOS (5.2 days vs 6 days, P = 0.03) and greater discharge home (72% vs 50%, P < 0.01). CONCLUSIONS Physician-led co-management plus a multidisciplinary improvement programme may reduce LOS and improve functional outcomes in older vascular surgical patients.
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Affiliation(s)
- Alison M Mudge
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Prue McRae
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Peter J Donovan
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michael C Reade
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Banning LBD, Visser L, Zeebregts CJ, van Leeuwen BL, El Moumni M, Pol RA. Transition in Frailty State Among Elderly Patients After Vascular Surgery. World J Surg 2021; 44:3564-3572. [PMID: 32494998 PMCID: PMC7458900 DOI: 10.1007/s00268-020-05619-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Frailty in the vascular surgical ward is common and predicts poor surgical outcomes. The aim of this study was to analyze transitions in frailty state in elderly patients after vascular surgery and to evaluate influence of patient characteristics on this transition. METHODS Between 2014 and 2018, 310 patients, ≥65 years and scheduled for elective vascular surgery, were included in this cohort study. Transition in frailty state between preoperative and follow-up measurement was determined using the Groningen Frailty Indicator (GFI), a validated tool to measure frailty in vascular surgery patients. Frailty is defined as a GFI score ≥4. Patient characteristics leading to a transition in frailty state were analyzed using multivariable Cox regression analysis. RESULTS Mean age was 72.7 ± 5.2 years, and 74.5% were male. Mean follow-up time was 22.7 ± 9.5 months. At baseline measurement, 79 patients (25.5%) were considered frail. In total, 64 non-frail patients (20.6%) shifted to frail and 29 frail patients (9.4%) to non-frail. Frail patients with a high Charlson Comorbidity Index (HR = 0.329 (CI: 0.133-0.812), p = 0.016) and that underwent a major vascular intervention (HR = 0.365 (CI: 0.154-0.865), p = 0.022) had a significantly higher risk to remain frail after the intervention. CONCLUSIONS The results of this study, showing that after vascular surgery almost 21% of the non-frail patients become frail, may lead to a more effective shared decision-making process when considering treatment options, by providing more insight in the postoperative frailty course of patients.
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Affiliation(s)
- Louise B D Banning
- Department of Surgery, Division of Vascular Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Linda Visser
- Department of Surgery, Division of Vascular Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, Groningen, The Netherlands
| | - Mostafa El Moumni
- Department of Surgery, Division of Trauma Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery, Division of Vascular Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
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10
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Frailty is a Poor Predictor of Postoperative Morbidity and Mortality After Ruptured Abdominal Aortic Aneurysm. Ann Vasc Surg 2021; 74:122-130. [PMID: 33549774 DOI: 10.1016/j.avsg.2020.12.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/04/2020] [Accepted: 12/20/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Frailty has gained prominence as a predictor of postoperative outcomes across a number of surgical specialties, vascular surgery included. The role of frailty is less defined in the acute surgical setting. We assessed the prognostic value of frailty for patients undergoing surgery for a ruptured abdominal aortic aneurysm (rAAA). METHODS A single-institution retrospective chart review of all patients undergoing surgical intervention for rAAA between January 1, 2011 and November 27, 2019 was performed. Frailty was assessed for each patient using the modified frailty index (mFI), a validated frailty metric based on the Canadian Study of Health and Aging. Frailty was defined as an mFI ≥0.27. The performance of the mFI was compared to that of the Vascular Study Group of New England (VSGNE) rAAA mortality risk score. Chi square, Fisher's exact, and t tests, were used to evaluate for associations between frailty and in-hospital outcomes. Univariate and multivariate logistic regression were used to obtain odds ratios for in-hospital mortality. A receiver operating characteristic (ROC) curve was generated to compare the predictive value of the mFI and VSGNE score for in-hospital mortality. RESULTS Sixty patients were identified during the study period with an in-hospital mortality rate of 37%. Twenty-one patients were deemed frail by mFI metric and included all patients with known myocardial infarction, stroke with a neurologic deficit or dependent functional status, however the mortality rate did not differ significantly based on frailty status (33% nonfrail vs. 43% frail, P= 0.47). Frailty status was not significantly different for patients with acute kidney injury (10% nonfrail vs. 10% frail), prolonged intubation (13% vs. 5%), abdominal compartment syndrome (8% vs. 10%), and Type I or Type III endoleak (8% vs. 19%). On multivariate analysis controlling for systolic blood pressure <70 mm Hg, suprarenal aortic control, and creatinine >2.0 mg/dl, the mFI produced an adjusted odds ratio (aOR) of 0.7 (95% confidence interval [CI]: 0.2-3.0). The ROC curve for the mFI produced an area under the curve (AUC) of 0.55 (P= 0.55) for in-hospital mortality while that of the VSGNE score produced an AUC of 0.69 (P= 0.02). CONCLUSIONS The mFI did not significantly predict in-hospital outcomes after rAAA in this cohort. This suggests that the baseline health status of a patient with rAAA may play a less significant role in their postoperative prognosis than their acuity on presentation.
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Houghton JSM, Nickinson ATO, Morton AJ, Nduwayo S, Pepper CJ, Rayt HS, Gray LJ, Conroy SP, Haunton VJ, Sayers RD. Frailty Factors and Outcomes in Vascular Surgery Patients: A Systematic Review and Meta-analysis. Ann Surg 2020; 272:266-276. [PMID: 32675539 DOI: 10.1097/sla.0000000000003642] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe and critique tools used to assess frailty in vascular surgery patients, and investigate its associations with patient factors and outcomes. BACKGROUND Increasing evidence shows negative impacts of frailty on outcomes in surgical patients, but little investigation of its associations with patient factors has been undertaken. METHODS Systematic review and meta-analysis of studies reporting frailty in vascular surgery patients (PROSPERO registration: CRD42018116253) searching Medline, Embase, CINAHL, PsycINFO, and Scopus. Quality of studies was assessed using Newcastle-Ottawa scores (NOS) and quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria. Associations of frailty with patient factors were investigated by difference in means (MD) or expressed as risk ratios (RRs), and associations with outcomes expressed as odds ratios (ORs) or hazard ratios (HRs). Data were pooled using random-effects models. RESULTS Fifty-three studies were included in the review and only 8 (15%) were both good quality (NOS ≥ 7) and used a well-validated frailty measure. Eighteen studies (62,976 patients) provided data for the meta-analysis. Frailty was associated with increased age [MD 4.05 years; 95% confidence interval (CI) 3.35, 4.75], female sex (RR 1.32; 95% CI 1.14, 1.54), and lower body mass index (MD -1.81; 95% CI -2.94, -0.68). Frailty was associated with 30-day mortality [adjusted OR (AOR) 2.77; 95% CI 2.01-3.81), postoperative complications (AOR 2.16; 95% CI 1.55, 3.02), and long-term mortality (HR 1.85; 95% CI 1.31, 2.62). Sarcopenia was not associated with any outcomes. CONCLUSION Frailty, but not sarcopenia, is associated with worse outcomes in vascular surgery patients. Well-validated frailty assessment tools should be preferred clinically, and in future research.
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Affiliation(s)
- John S M Houghton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
| | - Andrew T O Nickinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
| | | | - Sarah Nduwayo
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
| | - Coral J Pepper
- Library Service, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Harjeet S Rayt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Simon P Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Victoria J Haunton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rob D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
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Czobor NR, Lehot JJ, Holndonner-Kirst E, Tully PJ, Gal J, Szekely A. Frailty In Patients Undergoing Vascular Surgery: A Narrative Review Of Current Evidence. Ther Clin Risk Manag 2019; 15:1217-1232. [PMID: 31802876 PMCID: PMC6802734 DOI: 10.2147/tcrm.s217717] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/01/2019] [Indexed: 12/13/2022] Open
Abstract
Frailty is presumably associated with an elevated risk of postoperative mortality and adverse outcome in vascular surgery patients. The aim of our review was to identify possible methods for risk assessment and prehabilitation in order to improve recovery and postoperative outcome. The literature search was performed via PubMed, Embase, OvidSP, and the Cochrane Library. We collected papers published in peer-reviewed journals between 2001 and 2018. The selection criterion was the relationship between vascular surgery, frailty and postoperative outcome or mortality. A total number of 52 publications were included. Frailty increases the risk of non-home discharge independently of presence or absence of postoperative complications and it is related to a higher 30-day mortality and major morbidity. The modified Frailty Index showed significant association with elevated risk for post-interventional stroke, myocardial infarction, prolonged in-hospital stays and higher readmission rates. When adjusted for comorbidity and surgery type, frailty seems to impact medium-term survival (within 2 years). Preoperative physical exercising, avoidance of hypalbuminemia, psychological and cognitive training, maintenance of muscle strength, adequate perioperative nutrition, and management of smoking behaviours are leading to a reduced length of stay and a decreased incidence of readmission rate, thus improving the effectiveness of early rehabilitation. Pre-frailty is a dynamically changing state of the patient, capable of deteriorating or improving over time. With goal-directed preoperative interventions, the decline can be prevented.
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Affiliation(s)
- Nikoletta Rahel Czobor
- Medical Centre of Hungarian Defense Forces, Department of Anesthesiology and Intensive Care, Budapest, Hungary.,Semmelweis University, School of Doctoral Studies, Budapest, Hungary
| | - Jean-Jacques Lehot
- Claude-Bernard University, Health Services and Performance Research Lab (EA 7425 HESPER), Lyon, France.,Hôpital Neurologique Pierre Wertheimer, Department of Neuroanesthesia and Intensive Care, Hospices Civils de Lyon, Lyon, France
| | - Eniko Holndonner-Kirst
- Medical Centre of Hungarian Defense Forces, Department of Anesthesiology and Intensive Care, Budapest, Hungary
| | - Phillip J Tully
- University of Adelaide, Freemasons Foundation Centre for Men's Health, Adelaide, Australia
| | - Janos Gal
- Semmelweis University, Department of Anesthesiology and Intensive Care, Budapest, Hungary
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Care, Budapest, Hungary.,Semmelweis University, Heart and Vascular Center of Városmajor, Budapest, Hungary
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Antoniou GA, Rojoa D, Antoniou SA, Alfahad A, Torella F, Juszczak MT. Effect of Low Skeletal Muscle Mass on Post-operative Survival of Patients With Abdominal Aortic Aneurysm: A Prognostic Factor Review and Meta-Analysis of Time-to-Event Data. Eur J Vasc Endovasc Surg 2019; 58:190-198. [DOI: 10.1016/j.ejvs.2019.03.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/25/2019] [Accepted: 03/01/2019] [Indexed: 01/06/2023]
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Drudi LM, Ades M, Landry T, Gill HL, Grenon SM, Steinmetz OK, Afilalo J. Scoping review of frailty in vascular surgery. J Vasc Surg 2019; 69:1989-1998.e2. [DOI: 10.1016/j.jvs.2018.10.053] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/10/2018] [Indexed: 12/21/2022]
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Wang J, Zou Y, Zhao J, Schneider DB, Yang Y, Ma Y, Huang B, Yuan D. The Impact of Frailty on Outcomes of Elderly Patients After Major Vascular Surgery: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2018; 56:591-602. [DOI: 10.1016/j.ejvs.2018.07.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/09/2018] [Indexed: 01/10/2023]
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Juszczak MT, Taib B, Rai J, Iazzolino L, Carroll N, Antoniou GA, Neequaye S, Torella F. Total psoas area predicts medium-term mortality after lower limb revascularization. J Vasc Surg 2018; 68:1114-1125.e1. [DOI: 10.1016/j.jvs.2018.01.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/16/2018] [Indexed: 01/22/2023]
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Furukawa H, Yamane N, Honda T, Yamasawa T, Kanaoka Y, Tanemoto K. Initial clinical evaluation of preoperative frailty in surgical patients with Stanford type A acute aortic dissection. Gen Thorac Cardiovasc Surg 2018; 67:208-213. [PMID: 30136032 DOI: 10.1007/s11748-018-0994-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/17/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND We retrospectively assessed the initial clinical role of preoperative frailty in surgical patients with Stanford type A acute aortic dissection (AAAD). METHODS One hundred and fourteen consecutive patients who underwent emergent or urgent surgical interventions for AAAD in our institute between April 2000 and March 2016 participated in this retrospective study. Patients with more than three of the following six modalities were defined as being frail: age older than 75 years, preoperative requirement of assistance in daily living, body mass index less than 18.5 kg/m2, female, history of major stroke, and chronic kidney disease greater than class 3b. Twenty-three patients (20.2%) were diagnosed with frailty (group F), while 91 patients (79.8%) were not (group N). Early clinical outcomes, major postoperative complications, postoperative recovery of activity, and early or mid-term survival were evaluated. RESULTS Although early clinical outcomes and the prevalence of major postoperative complications were similar in both groups, postoperative activity of daily living (ADL), such as the rate of being ambulatory on discharge (p < 0.05) and home discharge (p < 0.01), was significantly lower in group F than in group N. A Kaplan-Meier analysis revealed that 1- and 5-year survival rates were similar in groups F (85.9 and 76.4%, respectively) and N (86.0 and 76.9%, respectively). CONCLUSIONS Preoperative frailty in AAAD surgical patients has potential as a prognostic factor that affects delays in ADL recovery, but does not influence the early or mid-term clinical outcomes of prompt surgical strategies for life rescue in AAAD patients with frailty.
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Affiliation(s)
- Hiroshi Furukawa
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan.
| | - Naoki Yamane
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Takeshi Honda
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Takahiko Yamasawa
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Yuji Kanaoka
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan
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Sweeting MJ, Ulug P, Roy J, Hultgren R, Indrakusuma R, Balm R, Thompson MM, Hinchliffe RJ, Thompson SG, Powell JT. Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm. Br J Surg 2018; 105:1135-1144. [PMID: 30461007 PMCID: PMC6055637 DOI: 10.1002/bjs.10820] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/16/2017] [Accepted: 12/13/2017] [Indexed: 01/19/2023]
Abstract
Background The aim of this study was to develop a 48‐h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C‐statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48‐h mortality in the IMPROVE data was reasonable (C‐statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C‐statistic was estimated compared with using age alone. Conclusion The assessed risk scores did not have sufficient accuracy to enable potentially life‐saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non‐intervention rates, while respecting the wishes of the patient and family. Not much help
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Affiliation(s)
- M J Sweeting
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - P Ulug
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - J Roy
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - R Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - R Indrakusuma
- Department of Vascular Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - R Balm
- Department of Vascular Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M M Thompson
- Stanford School of Medicine, Stanford, California, USA
| | - R J Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | - S G Thompson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - J T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
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Sridharan ND, Chaer RA, Wu BB, Eslami MH, Makaroun MS, Avgerinos ED. An Accumulated Deficits Model Predicts Perioperative and Long-term Adverse Events after Carotid Endarterectomy. Ann Vasc Surg 2017; 46:97-103. [PMID: 28689950 DOI: 10.1016/j.avsg.2017.06.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/02/2017] [Accepted: 06/16/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is increasing recognition that decreased reserve in multiple organ systems, known as accumulated deficits (AD), may better stratify perioperative risk than traditional risk indices. We hypothesized that an AD model would predict both perioperative adverse events and long-term survival after carotid endarterectomy (CEA), particularly important in asymptomatic patients. METHODS Consecutive patients undergoing CEA between 1st January 2000 and 31st December 2010 were retrospectively identified. Seven of the deficit items from the Canadian Study of Health and Aging-frailty index (coronary disease, renal insufficiency, pulmonary disease, peripheral vascular disease, heart failure, hypertension, and diabetes) were tabulated for each patient. Predictors of perioperative and long-term outcomes were evaluated using regression analysis. RESULTS About 1,782 CEAs in 1,496 patients (mean age: 71.3 ± 9.3 years, 56.3% male, 35.4% symptomatic) were included. The risk of major adverse events (stroke, death, or myocardial infarction) at 30 days for patients with ≤3 deficits was 2.53% vs. 8.81% for patients with ≥4 deficits (P < 0.001). For patients with ≥5 deficits, the risk was 15.18%. Each additional deficit increased the odds of a 30-day major adverse event and hospital stay >2 days by 1.64 (P < 0.001) and 1.15 (P < 0.001), respectively. In multivariate analysis, the presence of ≥4 deficits was more predictive of perioperative major adverse events (odds ratio [OR] = 3.62, P < 0.001) than symptomatology within 6 months (OR = 1.57, P = 0.08) or octogenarian status (OR = 2.00, P = 0.02). Kaplan-Meier analysis showed significantly decreased survival over time with accumulating deficits (P < 0.001). Patients with ≥4 deficits have a hazards ratio for death of 2.6 compared to patients with ≤3 deficits (P < 0.001). Overall survival is estimated at 79.5% (95% confidence interval [CI]: 0.77-0.82) at 5 years in patients with ≤3 deficits versus 52.4% (95% CI: 0.46-0.58) in patients with ≥4 deficits, respectively. In subgroup analysis of asymptomatic patients, 5-year survival for octogenarian male patients with ≥4 deficits was only 26.8%. For asymptomatic males aged 70-79 years with ≥4 deficits, 5-year survival was 59.9%. CONCLUSIONS An AD model is more predictive of perioperative adverse events after CEA than age or symptomatic status. This model remains predictive of long-term survival. In asymptomatic male octogenarians with 4 or more AD, 5-year survival is severely limited.
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Affiliation(s)
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Bryan Boyuan Wu
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Michel S Makaroun
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
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Ambler GK, Twine CP, Coughlin PA, Boyle JR. Regarding "Description of a risk predictive model of 30-day postoperative mortality after elective abdominal aortic aneurysm repair". J Vasc Surg 2017; 65:1546-1547. [PMID: 28434601 DOI: 10.1016/j.jvs.2016.10.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/25/2016] [Indexed: 10/19/2022]
Affiliation(s)
- Graeme K Ambler
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom; South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, United Kingdom
| | - Christopher P Twine
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom; South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, United Kingdom
| | - Patrick A Coughlin
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Drudi L, Phung K, Ades M, Zuckerman J, Mullie L, Steinmetz O, Obrand D, Afilalo J. Psoas Muscle Area Predicts All-Cause Mortality After Endovascular and Open Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2016; 52:764-769. [DOI: 10.1016/j.ejvs.2016.09.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/20/2016] [Indexed: 12/20/2022]
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Obeid T, Hicks CW, Yin K, Arhuidese I, Nejim B, Kilic A, Black JH, Malas M. Contemporary outcomes of open thoracoabdominal aneurysm repair: functional status is the strongest predictor of perioperative mortality. J Surg Res 2016; 206:9-15. [DOI: 10.1016/j.jss.2016.06.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 05/19/2016] [Accepted: 06/09/2016] [Indexed: 10/21/2022]
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Abdominal aortic aneurysm repair in octogenarians is associated with higher mortality compared with nonoctogenarians. J Vasc Surg 2016; 64:956-965.e1. [PMID: 27364946 DOI: 10.1016/j.jvs.2016.03.440] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/17/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Age is a well-known independent risk factor for death after abdominal aortic aneurysm (AAA) repair. However, there is significant debate about the utility of AAA repair in older patients. In this study, mortality outcomes after endovascular AAA repair (EVAR) and open AAA repair (OAR) in octogenarians (aged ≥80 years) were compared with younger patients (aged <80 years). METHODS All patients recorded in the Vascular Quality Initiative database (2002-2012) who underwent infrarenal AAA repair were included. Univariable and multivariable statistics were used to compare perioperative (30-day) and 1-year mortality outcomes between octogenarians vs nonoctogenarians for OAR and EVAR. RESULTS During the study period, 21,874 patients underwent AAA repair (OAR, 5765; EVAR, 16,109), including 4839 octogenarians (OAR, 765; EVAR, 4074) and 17,035 nonoctogenarians (OAR, 5000; EVAR, 12,035). Octogenarians (mean age, 83.0 ± 0.1 years) were less frequently male (66% vs 75%) and had a higher prevalence of congestive heart failure (9.9% vs 7.1%), chronic renal insufficiency (12.2% vs 7.5%), and a history of aortic surgery (14.3% vs 7.7%) compared with nonoctogenarians (P < .01 for all). Intraoperative use of blood transfusions and vasopressors was more common in octogenarians for OAR (blood: 3.3 ± 4.4 vs 1.8 ± 3.7 units; vasopressors: 45.2% vs 32.8%) and EVAR (blood: 0.43 ± 1.7 vs 0.31 ± 1.6 units; vasopressors: 7.6% vs 5.7%; P < .01 for all). Contrast dye volumes used during EVAR were similar in octogenarians and nonoctogenarians (108 ± 71 vs 107 ± 68 mL; P = .18). Perioperative mortality after OAR was 20.1% in octogenarians compared with 7.1% in nonoctogenarians (P < .01). Perioperative mortality after EVAR was 3.8% in the octogenarians compared with 1.6% in nonoctogenarians (P < .01). One-year mortality among octogenarians vs nonoctogenarians was 26% vs 9.7% for OAR and 8.9% vs 4.3% for EVAR (log-rank test, P < .01 for both). Multivariable analysis controlling for baseline and intraoperative differences between groups demonstrated that age ≥80 years increased the risk of 30-day and 1-year mortality after AAA repair by 223% and 187%, respectively (P < .01 for both). CONCLUSIONS AAA repair should be approached with extreme caution in octogenarians. Perioperative and 1-year mortality rates after OAR are particularly high in the older population, suggesting that the appropriate aneurysm size threshold for OAR might be larger due to the greater operative risk in octogenarian patients.
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