Surgical Frailty Is More Predictive To Postoperative Outcomes Than Emergent Status In Open Abdominal Aortic Aneurysm Repair: A VASQIP Analysis
Wayne Tse, MD, Kedar Lavingia, MD, Michael F. Amendola, MD.
VA Medical Center/VCU Health System, Richmond, VA, USA.
OBJECTIVES: Morbidity and mortality after an open abdominal aortic aneurysm (AAA) repair remain high even with advances in vascular surgery and critical care medicine. This is especially true for AAA repair performed under emergent circumstances. This study evaluates the contribution of frailty (determined by the risk analysis index) and other risk factors on postoperative outcomes after open AAA repair. METHODS: After obtaining IRB approval, VASQIP data was obtained for fiscal year 1998 to 2018. Cases were identified using CPT codes for open AAA repair. Pre-operative comorbidities and peri-operative variables were extracted from this database. The RAI score was calculated from several weighted preoperative variables. Incomplete records were excluded from this study. The patients were separated into 3 cohorts based on RAI score, non-frail (≤24), frail (25-34), and very frail (≥35). Data were analyzed with univariate analysis and forward stepwise logistic regression in SPSS (v27, IBM) to determine the risk factors for morbidity and mortality. Receiver operating characteristic (ROC) analysis was used to analyze the accuracy of prediction of postoperative outcomes.RESULTS: A total of 8,644 patients met inclusion criteria. The average age was 69.1 ± 7.8 years with 99.3% of the patients being male. The cohorts contained 3,615 (41.8%), 4,563 (52.7%), and 466 (5.4%) patients for non-frail, frail, and very frail, respectively. All postoperative complications including: 30-day mortality, any complication, return to operating room, cardiac, pulmonary, renal, and wound complications occurred in a dose dependent manner with respect to frailty (Table I). Very frail patients were 5 times more likely to experience a mortality in 30 days and almost 3 times as likely to have a complication compared to their non-frail counterparts (Table II). Frailty, when compared to an open AAA performed under an emergency circumstance, is more predictive of morbidity (AUC 0.59 (95% CI 0.58 - 0.61) vs 0.51 (0.50 - 0.53)) and mortality (AUC 0.65 (0.62 - 0.68) vs 0.54 (0.51 - 0.57). CONCLUSION: Frailty continues to be a critically important variable in determining outcomes for a patient undergoing an open AAA repair. 30-day mortality approaches prohibitively high mortality rates for very frail patients. This is critically important to consider and discuss with the patient when considering elective open AAA repair.
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