Frailty index predicts long-term mortality and postoperative complications in patients undergoing endovascular aortic aneurysm repair.

The Risk Analysis Index (RAI) has been used to evaluate preoperative frailty, which is associated with poor short- and long-term outcomes. We assessed this tool's ability to predict postoperative outcomes after endovascular aortic aneurysm repair. Institutional Review Board approval was obtained for this retrospective study. All patients who underwent elective endovascular aneurysm repair at a single Veterans Affairs Medical Center from December 2010 to March 2016 were included. Patients' characteristics and clinical data were retrospectively collected and analyzed. The RAI score was calculated from preoperative data, and a standard cutoff value (RAI ≥30) was used to determine frailty. Outcomes including postoperative complications, delayed discharge, and survival were compared between frail and nonfrail groups. Multivariate analysis was performed to evaluate preoperative factors associated with these outcomes. There were 134 patients who met inclusion criteria. There were 44 frail patients (RAI ≥30) and 90 nonfrail patients (RAI <30). Frail patients had a longer hospital stay (3.9 ± 4.0 days vs 2.3 ± 1.6 days; P = .02), increased operative time (155 ± 30 minutes vs 138 ± 30 minutes; P = .002), and increased postoperative complications (43% vs 21%; P = .02) compared with nonfrail patients. Kaplan-Meier average survival for frail patients and nonfrail patients was 60 ± 4 months and 84 ± 3 months (P < .001), respectively. In multivariate analyses, frailty was associated with worse overall survival (hazard ratio, 3.7; 95% confidence interval [CI], 1.8-7.3) and higher odds of complications (odds ratio, 1.1; 95% CI, 1.0-1.14) and delayed discharge (odds ratio, 1.1; 95% CI, 1.05-1.2). Preoperative frailty as evaluated by the RAI is associated with worse short-term postoperative outcomes and long-term mortality. The RAI can be used to inform risk-benefit discussions with patients and their families.

Tse W ，Newton D ，Amendola M ，George M ，Pfeifer J ... -  《-》

Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms.

Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database. Patients undergoing elective open and endovascular AAA repair (2003-2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with ≥10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI ≥35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year. A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F = 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001). There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair.

George EL ，Chen R ，Trickey AW ，Brooke BS ，Kraiss L ，Mell MW ，Goodney PP ，Johanning J ，Hockenberry J ，Arya S ... -  《-》

The Administrative Risk Analysis Index (RAI-A) Does Not Predict Reintervention or Mortality Within 30 Days in Patients Who Undergo Elective Open or Endovascular Abdominal Aortic Aneurysm Repair.

Frailty scores are increasingly utilized to predict postoperative complications. The purpose of this study is to determine whether the administrative risk analysis index (RAI-A) can be used to predict reintervention or mortality within 30 days in patients who undergo elective open or endovascular abdominal aortic aneurysm (AAA) repair. The American College of Surgeons National Surgical Quality Improvement Program database was used to query data from elective open or endovascular aortic aneurysm repairs from 2011 to 2018. The administrative risk analysis index (RAI-A) score was calculated for each patient using two approaches (conservative versus liberal) due to discrepancies in NSQIP data categorization. Multivariable regression analysis was performed to determine whether there were statistical or clinical significance for incremental increases of RAI-A for both the open and endovascular repair group. Outcome measures were re-intervention or death within 30 days. Data from 4106 and 11,733 patients who underwent open and endovascular repair, respectively, were included in the analysis. The number of reinterventions within 30 days was 9.1% (375 out of 4106 patients) in the open repair group and 4.0% (463 out of 11,685 patients) in the endovascular group. Thirty-day mortality was 4.7% (192 out of 4106 patients) in the open repair group, and 0.9% (109 out of 11,685 patients) in the endovascular group. In the conservative calculation of RAI-A scores, the open and endovascular repair groups had median RAI-A scores of 7 (mean 8.31) and 9 (mean 9.51), respectively. There was no significant association between RAI-A scores and outcome measures in either group. For predicting 30 d reintervention, the C statistic was 0.535 (OR 1.02) for the open repair group and 0.532 (OR 1.02) for endovascular repair. For predicting 30-day mortality, the C statistic was 0.626 (OR 1.07) in the open repair group and 0.701 (OR 1.09) in the endovascular repair group. In the liberal calculation of RAI-A scores, the open and endovascular repair groups had median RAI-A scores of 6 (mean 6.19) and 7 (mean 7.65), respectively. There was no significant association between RAI-A scores and outcome measures in either group. For predicting 30 d reintervention, the C statistic was 0.527 (OR 1.02) for open repair and 0.529 (OR 1.02) for endovascular repair. For predicting 30-day mortality, the C statistic was 0.625 (OR 1.07) in the open repair group and 0.695 (OR 1.08) in the endovascular repair group. The RAI-A is not useful in predicting 30 d reintervention or mortality in patients who undergo elective open or endovascular AAA repair.

Man J ，Xu J 《-》

Using the risk analysis index to assess frailty in a veteran cohort undergoing endovascular aortic aneurysm repair.

Surgical frailty is strongly associated with increased perioperative morbidity and mortality. The risk analysis index (RAI) is a validated frailty score system, which has been shown to predict for short-term outcomes and long-term mortality in various surgical subspecialties. In the present study, we applied the frailty score to a veteran aneurysm population who had undergone nonemergent endovascular aortic aneurysm repair (EVAR). After obtaining institutional review board approval, the Veteran Affairs Surgical Quality Improvement Program data were queried for endovascular repair of infrarenal abdominal aortic aneurysm or dissection using the Current Procedural Terminology codes 34,800, 34,803, and 34,805 from 2001 to 2018. The preoperative variables were used to calculate the RAI score. The patients were placed into six cohorts according to the RAI score (≤20, 21-25, 26-30, 31-35, 35-40, and ≥41). The χ2 test and analysis of variance test were used compare the cohorts. Forward logistic regression modeling was used to determine the risks of each cohort. From 2001 to 2018, 5568 patients had undergone EVAR. Of the 5568 patients, 99.6% were male, with a mean age of 71 ± 8 years. Of these patients, 4.5%, 43.8%, 33.9%, 11.7%, 4.2%, and 1.8% were included in the following RAI groups: ≤20, 21 to 25, 26 to 30, 31 to 35, 35 to 40, and ≥41, respectively. Frailty was associated with increased rates of overall complications, death, and an increased length of stay. When risk adjusted, frailty at the highest vs lowest level was associated with 2.7 times the odds of any complication developing and 4.4 times the odds of mortality ≤30 days. Frailty, as determined by the RAI, was associated with postoperative outcomes in a dose-dependent manner. Frailty was associated with higher rates of major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean from ventilation, reintubation), renal (renal failure), overall complications, length of stay, and death. We recommend the use of this frailty index as a screening tool to guide discussions with patients scheduled to undergo EVAR.

Tse W ，Lavingia KS ，Amendola MF 《-》

Frailty Among Veterans Undergoing Abdominal Aortic Aneurysm Repair.

Frailty is a known risk factor for adverse outcomes following surgery and affects at least 3 of every 10 US Veterans aged 65 years and older. We designed a study to characterize the association between frailty and complications after endovascular aneurysm repair (EVAR) compared to open aneurysm repair (OAR) at our regional Veterans Affairs Medical Center. Veterans who underwent either OAR or EVAR at our institution between January 1, 2000 and December 31, 2020 were identified. We examined medical history, procedure characteristics, perioperative complications, and frailty as measured by the 5-factor modified frailty index (mFI-5). Frailty was defined as an mFI-5 score ≥2. Primary endpoints were postoperative complications, duration of surgery, and length of hospital stay. Tests of association were performed with t-test and chi-squared analysis. Over the 21-year period, we identified 314 patients that underwent abdominal aortic aneurysm (AAA) repair with 115 (36.6%) OAR and 199 EVAR (63.4%) procedures. Patients undergoing EVAR were older on average (72.1 years vs. 70.2 years) and had a higher average mFI-5 compared to the open repair group (1.49 vs. 1.23, P = 0.036). When comparing EVAR and OAR cohorts, patients undergoing OAR had a larger AAA diameter (6.5 cm, standard deviation [SD]: 1.5) compared to EVAR (5.5 cm, SD: 1.1 P < 0.0001). Fewer frail patients underwent OAR (n = 40, 34.8%) compared to EVAR (n = 86, 43.2%), and frail EVAR patients had higher AAA diameter (5.8 cm, SD: 1.0) compared to nonfrail EVAR patients (5.3 cm, SD 1.2), P = 0.003. Among OAR procedures, frail patients had longer operative times (296 min vs. 253 min, P = 0.013) and higher incidence of pneumonia (17.5% vs. 5.3%, P = 0.035). Among frail EVAR patients, operative time and perioperative complications including wound dehiscence, surgical site infection, and pneumonia were not significantly different than their nonfrail counterparts. Overall, frail patients had more early complications (n = 55, 43.7%) as compared to nonfrail patients (n = 48, 25.5%, P = 0.001). OAR patients had higher rates of postoperative complications including wound dehiscence (7.0% vs. 0.5%, P = 0.001), surgical site infections (7.0% vs. 1.0%, P = 0.003), and pneumonia (9.6% vs. 0.5%, P=<0.0001). Open repair was also associated with overall longer average intensive care unit stays (11.0 days vs. 1.6 days, P < 0.0001) and longer average hospitalizations (13.5 days vs. 2.4 days, P < 0.0001). Our findings demonstrate that frailty is associated with higher rates of adverse outcomes in open repair compared to EVAR. Patients who underwent open repair had higher rates of wound dehiscence, surgical site infection, and pneumonia, compared to those undergoing endovascular repair. Frailty was associated with larger AAA diameter in the EVAR cohort and longer operative times, with higher frequency of postoperative pneumonia in the OAR cohort. Frailty is a strong risk factor that should be considered in the management of aortic aneurysms.

Chen AJ ，Yeh SL ，Ulloa JG ，Gelabert HA ，Rigberg DA ，de Virgilio CM ，O'Connell JB ... -  《-》