Impact of Frailty on Postoperative Outcomes in Patients Undergoing TransCarotid Artery Revascularization (TCAR)

Published:March 02, 2022DOI:


      Frailty is a clinical syndrome characterized by a reduction in metabolic reserves leading to increased susceptibility to adverse outcomes following invasive surgical interventions. The 5-item modified frailty index (mFI-5) validated in prior studies has shown high predictive accuracy for all surgical specialties, including vascular procedures. In this study, we aim to utilize the mFI-5 to predict outcomes in Transcarotid Revascularization (TCAR).


      All patients who underwent TCAR from November 2016 to April 2021 in the Vascular Quality Initiative (VQI) Database were included. The mFI-5 was calculated as a cumulative score divided by 5 with 1 point each for poor functional status, presence of diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and hypertension. Patients were stratified into two groups based on prior studies: low mFI-5 (0.6) and high (≥0.6). Primary outcomes included in-hospital death, extended length of postoperative stay (>1 day), and nonhome discharge. Secondary outcomes included in-hospital stroke, transient ischemic attack (TIA), myocardial infarction (MI), a composite endpoint of stroke/death, stroke/TIA, and stroke/death/MI. Univariate and multivariable logistic regression were used to assess the association between mFI-5 and postoperative outcomes. Secondary analysis stratified by symptomatic status was performed.


      Out of the 17,983 patients who underwent TCAR, 4526(25.2%) had mFI-5 score of ≥0.6 and considered clinically frail. Compared to the nonfrail group, frail patients were more likely to be female (38.7% vs. 35.6%, P < 0.001), have poor functional status (43.6 vs. 8.3%, P < 0.001), and present with significant comorbidities, including diabetes (75.3% vs. 26.1%, P < 0.001), hypertension (98.9% vs. 88.5%, P < 0.001), CHF (52.2% vs. 5.6, P < 0.001), and COPD (60.3% vs. 14.2%, P < 0.001). They were also more likely to be active smokers (25.4% vs. 20.4%, P < 0.001) and symptomatic prior to intervention (28.7% vs. 25.3%, P < 0.001). On univariate analysis, frail patients were at significantly higher risk to experience adverse outcomes, including in-hospital mortality, TIA, MI, stroke/death, stroke/TIA, stroke/death/MI, discharge to nonhome facility, and extended LOS. After adjusting for potential confounders, frail patients remained at significantly higher risk of in-hospital mortality [aOR 2.26(1.41,3.61), P = 0.001], TIA [aOR 1.65(1.08, 2.54), P = 0.040], nonhome discharge [aOR 1.99(1.71,2.32) P < 0.001], and extended LOS [aOR 1.41(1.27, 1.55) P < 0.001]. On further stratified analysis based on symptomatic status, the increased risk of stroke/death, TIA, and death was observed only in symptomatic patients.


      Modified Frailty Index is a reliable tool that can be used to identify high-risk patients for TCAR prior to intervention. This could help vascular surgeons, patients, and families in informed decision making to further optimize perioperative care and medical management in frail patients.
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      • Transcarotid Artery Revascularization (TCAR) in the Frail
        Annals of Vascular SurgeryVol. 84
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          Transfemoral carotid stenting (TFCAS) fell dramatically out of favor with vascular surgeons after the results of the CREST trial showed higher rates of stroke compared to carotid endarterectomy (CEA).1 The emergence of TCAR presented a novel technology to stent carotid lesions in patients not suitable or considered high risk for a CEA. Multiple recent studies evaluating the outcomes of TCAR have been very encouraging.2–4 This has led to fast and wide adoption of the technique.
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