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

Published:March 02, 2022DOI:https://doi.org/10.1016/j.avsg.2021.12.085

      Background

      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).

      Methods

      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.

      Results

      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.

      Conclusions

      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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      References

        • Hoogendijk E.O.
        • Afilalo J.
        • Ensrud K.E.
        • et al.
        Frailty: implications for clinical practice and public health.
        Lancet Lond Engl. 2019; 394: 1365-1375
        • Makary M.A.
        • Segev D.L.
        • Pronovost P.J.
        • et al.
        Frailty as a predictor of surgical outcomes in older patients.
        J Am Coll Surg. 2010; 210: 901-908
        • Mathers C.D.
        • Stevens G.A.
        • Boerma T.
        • et al.
        Causes of international increases in older age life expectancy.
        Lancet Lond Engl. 2015; 385: 540-548
        • Kojima G.
        • Iliffe S.
        • Walters K.
        Frailty index as a predictor of mortality: a systematic review and meta-analysis.
        Age Ageing. 2018; 47: 193-200
        • Ehlert B.A.
        • Najafian A.
        • Orion K.C.
        • et al.
        Validation of a modified Frailty Index to predict mortality in vascular surgery patients.
        J Vasc Surg. 2016; 63: 1595-1601.e2
        • Subramaniam S.
        • Aalberg J.J.
        • Soriano R.P.
        • et al.
        New 5-Factor modified frailty index using American College of surgeons NSQIP data.
        J Am Coll Surg. 2018; 226: 173-181.e8
        • Pandit V.
        • Zeeshan M.
        • Nelson P.R.
        • et al.
        Frailty syndrome in patients with carotid disease: Simplifying How We calculate frailty.
        Ann Vasc Surg. 2020; 62: 159-165
        • Czobor N.R.
        • Lehot J.-J.
        • Holndonner-Kirst E.
        • et al.
        Frailty in patients undergoing vascular surgery: a Narrative review of Current evidence.
        Ther Clin Risk Manag. 2019; 15: 1217-1232
        • Scarborough J.E.
        • Bennett K.M.
        • Englum B.R.
        • et al.
        The impact of functional dependency on outcomes after complex general and vascular surgery.
        Ann Surg. 2015; 261: 432-437
        • Pandit V.
        • Lee A.
        • Zeeshan M.
        • et al.
        Effect of frailty syndrome on the outcomes of patients with carotid stenosis.
        J Vasc Surg. 2020; 71: 1595-1600
        • Ishihara H.
        • Oka F.
        • Goto H.
        • et al.
        Impact of frailty on Medium-term outcome in asymptomatic patients after carotid artery stenting.
        World Neurosurg. 2019; 127: e396-e399
        • Kwolek C.J.
        • Jaff M.R.
        • Leal J.I.
        • et al.
        Results of the ROADSTER multicenter trial of transcarotid stenting with dynamic flow reversal.
        J Vasc Surg. 2015; 62: 1227-1234.e1
        • Malas M.B.
        • Dakour-Aridi H.
        • Wang G.J.
        • et al.
        Transcarotid artery revascularization versus transfemoral carotid artery stenting in the Society for vascular surgery vascular Quality Initiative.
        J Vasc Surg. 2019; 69: 92-103.e2
        • Naazie I.
        • Cui C.
        • Osaghae I.
        • et al.
        A systematic review and meta-analysis of transcarotid artery revascularization with dynamic flow reversal versus transfemoral carotid artery stenting and carotid endarterectomy.
        Ann Vasc Surg. 2020; https://doi.org/10.1016/j.avsg.2020.05.070
        • Dakour-Aridi H.
        • Kashyap V.S.
        • Wang G.J.
        • et al.
        The impact of age on in-hospital outcomes after transcarotid artery revascularization, transfemoral carotid artery stenting, and carotid endarterectomy.
        J Vasc Surg. 2020; 72: 931-942.e2
        • Dakour Aridi H.
        • Elsayed N.
        • Malas M.
        Outcomes of carotid revascularization in patients with contralateral artery occlusion.
        J Am Coll Surg. 2021; 232: 699-708.e1
        • Elsayed N.
        • Yei K.S.
        • Naazie I.
        • et al.
        Impact of carotid lesion Calcification on outcomes after transfemoral versus transcarotid artery stenting.
        J Vasc Surg. 2022; 75
        • Elsayed N.
        • Ramakrishnan G.
        • Naazie I.
        • et al.
        Outcomes of carotid revascularization in the treatment of Restenosis after prior carotid endarterectomy.
        Stroke. 2021; 52: 3199-3208
        • Cronenwett J.L.
        • Kraiss L.W.
        • Cambria R.P.
        The Society for vascular surgery vascular Quality Initiative.
        J Vasc Surg. 2012; 55: 1529-1537
        • Etzioni D.A.
        • Liu J.H.
        • Maggard M.A.
        • et al.
        The aging population and its impact on the surgery Workforce.
        Ann Surg. 2003; 238: 170-177
        • Rawles J.W.
        • Beckstrom J.L.
        • Bailey T.R.
        • et al.
        IP245. Relationship between surgical stress and adverse postoperative outcomes among frail vascular surgery patients: How Much Does it Take to Push Them over the Edge?.
        J Vasc Surg. 2019; 69: e176-e177
        • Mehta A.
        • Patel P.B.
        • Bajakian D.
        • et al.
        Transcarotid artery revascularization versus carotid endarterectomy and transfemoral stenting in Octogenarians.
        J Vasc Surg. 2021; 74: 1602-1608
        • Schermerhorn M.L.
        • Liang P.
        • Dakour-Aridi H.
        • et al.
        In-hospital outcomes of transcarotid artery revascularization and carotid endarterectomy in the Society for Vascular Surgery Vascular Quality Initiative.
        J Vasc Surg. 2020; 71: 87-95
        • Malas M.B.
        • Dakour-Aridi H.
        • Kashyap V.S.
        • et al.
        TransCarotid revascularization with dynamic flow reversal versus carotid endarterectomy in the vascular Quality Initiative Surveillance project.
        Ann Surg. 2020; 15https://doi.org/10.1097/SLA.0000000000004496
      1. One-Year Results of the ROADSTER Multicenter Trial of Transcarotid Stenting With Dynamic Flow Reversal - Journal of Vascular Surgery.
        • Schermerhorn M.L.
        • Liang P.
        • Eldrup-Jorgensen J.
        • et al.
        Association of transcarotid artery revascularization vs transfemoral carotid artery stenting with stroke or death among patients with carotid artery stenosis.
        JAMA. 2019; 322: 2313-2322
        • Revenig L.M.
        • Canter D.J.
        • Master V.A.
        • et al.
        A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery.
        J Endourol. 2014; 28: 476-480
        • Shinall M.C.
        • Arya S.
        • Youk A.
        • et al.
        Association of preoperative patient frailty and operative stress with postoperative mortality.
        JAMA Surg. 2020; 155: e194620https://doi.org/10.1001/jamasurg.2019.4620
        • Pritchard J.M.
        • Kennedy C.C.
        • Karampatos S.
        • et al.
        Measuring frailty in clinical practice: a comparison of physical frailty assessment methods in a geriatric out-patient clinic.
        BMC Geriatr. 2017; 17: 264
        • Hall D.E.
        • Arya S.
        • Schmid K.K.
        • et al.
        Development and Initial validation of the risk analysis index for Measuring frailty in surgical populations.
        JAMA Surg. 2017; 152: 175
        • Dakour-Aridi H.
        • Faateh M.
        • Kuo P.-L.
        • et al.
        The Vascular Quality Initiative 30-day stroke/death risk score calculator after transfemoral carotid artery stenting.
        J Vasc Surg. 2020; 71: 526-534
        • Panayi A.C.
        • Orkaby A.R.
        • Sakthivel D.
        • et al.
        Impact of frailty on outcomes in surgical patients: a systematic review and meta-analysis.
        Am J Surg. 2019; 218: 393-400
        • Barbey S.M.
        • Scali S.T.
        • Kubilis P.
        • et al.
        Interaction between frailty and sex on mortality after elective abdominal aortic aneurysm repair.
        J Vasc Surg. 2019; 70: 1831-1843
        • Andersen J.C.
        • Gabel J.A.
        • Mannoia K.A.
        • et al.
        5-Item modified frailty index predicts outcomes after Below-Knee Amputation in the vascular Quality Initiative Amputation registry.
        Am Surg. 2020; 86: 1225-1229
        • Mandelbaum A.D.
        • Hadaya J.
        • Ulloa J.G.
        • et al.
        Impact of frailty on clinical outcomes after carotid artery revascularization.
        Ann Vasc Surg. 2021; 74: 111-121
        • Arya S.
        • Long C.A.
        • Brahmbhatt R.
        • et al.
        Preoperative frailty increases risk of Nonhome discharge after elective vascular surgery in home-Dwelling patients.
        Ann Vasc Surg. 2016; 35: 19-29
        • Ottenbacher K.J.
        • Karmarkar A.
        • Graham J.E.
        • et al.
        Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.
        JAMA. 2014; 311: 604-614
        • Edgerton J.R.
        • Herbert M.A.
        • Mahoney C.
        • et al.
        Long-term fate of patients discharged to extended care facilities after cardiovascular surgery.
        Ann Thorac Surg. 2013; 96: 871-877
        • Faateh M.
        • Kuo P.-L.
        • Dakour-Aridi H.
        • et al.
        Frailty as a predictor of outcomes for patients undergoing carotid artery stenting.
        J Vasc Surg. 2021; 74: 1290-1300
        • Wu W.W.
        • Liang P.
        • O’Donnell T.F.X.
        • et al.
        Anatomic eligibility for transcarotid artery revascularization and transfemoral carotid artery stenting.
        J Vasc Surg. 2019; 69: 1452-1460

      Linked Article

      • 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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