Sarcopenia is a Prognostic Biomarker for Long-Term Survival after Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis

Published:March 11, 2022DOI:


      Sarcopenia is the loss of muscle mass and strength. It manifests as decreased core muscle area in axial abdominal computed tomography scans. The predictive value of sarcopenia in outcome research has been widely discussed. A systematic review was conducted to assess sarcopenia as a biomarker in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) and its association with long-term survival.


      A systematic search of the English medical literature, published from 1991 to 2021, was conducted, using PubMed, EMBASE, and CENTRAL, as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA, 2020) guidelines. The study protocol was registered to the International Prospective Register of Systematic Reviews (CRD 42021260192). Observational studies reporting on sarcopenic and nonsarcopenic patients undergoing EVAR were included. The Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) risk of bias evaluation tool was used for the quality assessment. The outcomes were summarized as odds ratio (OR) along with their 95% confidence intervals (CI), through a paired meta-analysis. The primary outcome was 5-year survival following EVAR.


      Eleven observational studies, including 2,385 patients (89.6% males) treated with EVAR, between 1999 and 2018, were included in the qualitative synthesis. The mean age was 72.9 years (range 70–76.4 years). Nine of the studies reported on a negative prognostic value of sarcopenia on survival during a long-term follow-up. Six studies stratified their cohorts in sarcopenic versus nonsarcopenic patients (40.3% sarcopenic). The cutoff values (mm2 or mm2/m2) for defining sarcopenic patients were heterogeneous while ranging from 451 to 4,820 mm2/m2 and 1,207 to 11,400 mm2. Eight studies reported data on the mean follow-up duration, ranging from 27 to 101 months. Six studies reported on outcomes in terms of 5-year survival rates after EVAR, favoring nonsarcopenic over sarcopenic patients, with survival rates ranging from 58 to 93% and 24 to 60%, respectively. After a meta-analysis including 3 eligible studies, sarcopenia was associated with worse 5-year survival after EVAR (OR 0.77, 95% CI [0.58, 0.97], P < 0.001).


      The available data derived from observational studies suggest an association between sarcopenia and worse long-term survival in patients treated with EVAR. There is a lack of a universally accepted definition for sarcopenia and future reporting standards should address this issue. Prospective studies are necessary to establish this negative prognostic value of sarcopenia on long-term survival.
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        • National Vascular Registry, Clinical Effectiveness Unit, Royal College of Surgeons of England
        National vascular registry 2021 annual report | VSQIP.
        (Available at:)
        • Wanhainen A.
        • Verzini F.
        • Van Herzeele I.
        • et al.
        Editor’s choice - European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
        Eur J Vasc Endovasc Surg. 2019; 57: 8-93
        • Chaikof E.L.
        • Dalman R.L.
        • Eskandari M.K.
        • et al.
        The society for vascular surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.
        J Vasc Surg. 2018; 67: 2-77.e2
        • Howard D.P.J.
        • Banerjee A.
        • Fairhead J.F.
        • et al.
        Age-specific incidence, risk factors and outcome of acute abdominal aortic aneurysms in a defined population.
        Br J Surg. 2015; 102: 907-915
        • Grant S.W.
        • Grayson A.D.
        • Mitchell D.C.
        • et al.
        Evaluation of five risk prediction models for elective abdominal aortic aneurysm repair using the UK national vascular database.
        Br J Surg. 2012; 99: 673-679
        • Teixeira I.M.
        • Teles A.R.
        • Castro J.M.
        • et al.
        Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) system for outcome prediction in elderly patients undergoing major vascular surgery.
        J Cardiothorac Vasc Anesth. 2018; 32: 960-967
        • Thurston B.
        • Pena G.N.
        • Howell S.
        • et al.
        Low total psoas area as scored in the clinic setting independently predicts midterm mortality after endovascular aneurysm repair in male patients.
        J Vasc Surg. 2018; 67: 460-467
        • Waduud M.A.
        • Wood B.
        • Keleabetswe P.
        • et al.
        Influence of psoas muscle area on mortality following elective abdominal aortic aneurysm repair.
        Br J Surg. 2019; 106: 367-374
        • Cheng B.T.
        • Soult M.C.
        • Helenowski I.B.
        • et al.
        Sarcopenia predicts mortality and adverse outcomes after endovascular aneurysm repair and can be used to risk stratify patients.
        J Vasc Surg. 2019; 70: 1576-1584
        • Walston J.D.
        Sarcopenia in older adults.
        Curr Opin Rheumatol. 2012; 24: 623-627
        • Pahor M.
        • Manini T.
        • Cesari M.
        Sarcopenia: clinical evaluation, biological markers and other evaluation tools.
        J Nutr Health Aging. 2009; 13: 724-728
        • Sabatino A.
        • Cuppari L.
        • Stenvinkel P.
        • et al.
        Sarcopenia in chronic kidney disease: what have we learned so far?.
        J Nephrol. 2020; 34: 1347-1372
        • Zhang N.
        • Zhu W.L.
        • Liu X.H.
        • et al.
        Prevalence and prognostic implications of sarcopenia in older patients with coronary heart disease.
        J Geriatr Cardiol. 2019; 16: 756
        • Yoo T.
        • Lo W.D.
        • Evans D.C.
        Computed tomography measured psoas density predicts outcomes in trauma.
        Surgery. 2017; 162: 377-384
        • Zakaria H.M.
        • Wilkinson B.M.
        • Pennington Z.
        • et al.
        Sarcopenia as a prognostic factor for 90-day and overall mortality in patients undergoing spine surgery for metastatic tumors: a multicenter retrospective cohort study.
        Neurosurgery. 2020; 87: 1025-1036
        • Masuda T.
        • Shirabe K.
        • Ikegami T.
        • et al.
        Sarcopenia is a prognostic factor in living donor liver transplantation.
        Liver Transpl. 2014; 20: 401-407
        • Matsubara Y.
        • Matsumoto T.
        • Aoyagi Y.
        • et al.
        Sarcopenia is a prognostic factor for overall survival in patients with critical limb ischemia.
        J Vasc Surg. 2015; 61: 945-950
        • Ferreira J.M.M.
        • Cunha P.
        • Carneiro A.
        • et al.
        Sarcopenia as a prognostic factor in peripheral arterial disease: descriptive review.
        Ann Vasc Surg. 2021; 74: 460-474
        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • et al.
        The PRISMA 2020 statement: an updated guideline for systematic reviews.
        BMJ. 2021; 372: n71
        • Schardt C.
        • Adams M.B.
        • Owens T.
        • et al.
        Utilization of the PICO framework to improve searching PubMed for clinical questions.
        BMC Med Inform Decis Mak. 2007; 7: 16
        • Sterne J.A.
        • Hernán M.A.
        • Reeves B.C.
        • et al.
        ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.
        BMJ. 2016; 355: i4919
        • Santilli V.
        • Bernetti A.
        • Mangone M.
        • et al.
        Clinical definition of sarcopenia.
        Clin Cases Miner Bone Metab. 2014; 11: 177
        • Cruz-Jentoft A.J.
        • Baeyens J.P.
        • Bauer J.M.
        • et al.
        Sarcopenia: European consensus on definition and diagnosis: report of the European working group on sarcopenia in older people.
        Age Ageing. 2010; 39: 412-423
        • Muscaritoli M.
        • Anker S.D.
        • Argilés J.
        • et al.
        Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by special Interest Groups (SIG) “cachexia-anorexia in chronic wasting diseases” and “nutrition in geriatrics.
        Clin Nutr. 2010; 29: 154-159
        • Fielding R.A.
        • Vellas B.
        • Evans W.J.
        • et al.
        Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia.
        J Am Med Dir Assoc. 2011; 12: 249-256
        • Oliveira V.C.
        • Oliveira P.
        • Moreira M.
        • et al.
        Impact of total psoas area and lean muscular area on mortality after endovascular aortic aneurysm repair.
        Ann Vasc Surg. 2021; 72: 479-487
        • Smoor R.M.
        • Kropman R.H.J.
        • Brouwers S.E.M.
        • et al.
        Pre-operative low muscle mass is associated with mortality rate after elective abdominal aortic aneurysm repair.
        Eur J Vasc Endovasc Surg. 2021; 61: 169-170
        • Newton D.H.
        • Kim C.
        • Lee N.
        • et al.
        Sarcopenia predicts poor long-term survival in patients undergoing endovascular aortic aneurysm repair.
        J Vasc Surg. 2018; 67: e16-e17
        • Huber T.C.
        • Keefe N.
        • Patrie J.
        • et al.
        Predictors of all-cause mortality after endovascular aneurysm repair: assessing the role of psoas muscle cross-sectional area.
        J Vasc Interv Radiol. 2019; 30: 1972-1979
        • Indra Kusuma R.
        • Zijlmans J.L.
        • Jalalzadeh H.
        • et al.
        Psoas muscle area as a prognostic factor for survival in patients with an asymptomatic infrarenal abdominal aortic aneurysm: a retrospective cohort study.
        Eur J Vasc Endovasc Surg. 2018; 55: 83-91
        • Drudi L.M.
        • Phung K.
        • Ades M.
        • et al.
        Psoas muscle area predicts all-cause mortality after endovascular and open aortic aneurysm repair.
        Eur J Vasc Endovasc Surg. 2016; 52: 764-769
        • Ito E.
        • Ohki T.
        • Toya N.
        • et al.
        Sarcopenia aneurysm scoring system predicts early and midterm mortality after endovascular repair for abdominal aortic aneurysm.
        Ann Surg. 2020;
        • Hale A.L.
        • Twomey K.
        • Ewing J.A.
        • et al.
        Impact of sarcopenia on long-term mortality following endovascular aneurysm repair.
        Vasc Med. 2016; 21: 217-222
        • Rosenberg I.H.
        Sarcopenia: origins and clinical relevance.
        J Nutr. 1997; 127: 990S-991S
        • Chaikof E.L.
        • Blankensteijn J.D.
        • Harris P.L.
        • et al.
        Reporting standards for endovascular aortic aneuryms repair.
        J Vasc Surg. 2002; 35: 1048-1060
        • Spanos K.
        • Nana P.
        • Behrendt C.A.
        • et al.
        Management of abdominal aortic aneurysm disease: similarities and differences among cardiovascular guidelines and NICE guidance.
        J Endovasc Ther. 2020; 27: 889-901
        • Chae M.S.
        • Moon K.U.
        • Jung J.Y.
        • et al.
        Perioperative loss of psoas muscle is associated with patient survival in living donor liver transplantation.
        Liver Transpl. 2018; 24: 623-633
        • Kärkkäinen J.M.
        • Oderich G.S.
        • Tenorio E.R.
        • et al.
        Psoas muscle area and attenuation are highly predictive of complications and mortality after complex endovascular aortic repair.
        J Vasc Surg. 2021; 73: 1178-1188
        • Antoniou G.A.
        • Rojoa D.
        • Antoniou S.A.
        • et al.
        Effect of low skeletal muscle on post-operative survival of patients with abdominal aortic aneurysm: a prognostic factor review and meta-analysis of time-to-event data.
        Eur J Endovasc Surg. 2019; 58: 190-198
        • Wallace J.D.
        • Calvo R.Y.
        • Lewis P.R.
        • et al.
        Sarcopenia as a predictor of mortality in elderly blunt trauma patients: comparing the masseter to the psoas using computed tomography.
        J Trauma Acute Care Surg. 2017; 82: 65-70
        • Zakaria H.M.
        • Llaniguez J.T.
        • Telemi E.
        • et al.
        Sarcopenia predicts overall survival in patients with lung, breast, prostate, or myeloma spine metastases undergoing stereotactic body radiation therapy (SBRT), independent of histology.
        Neurosurgery. 2020; 86: 705-716
        • Trejo-Avila M.
        • Bozada-Gutiérrez K.
        • Valenzuela-Salazar C.
        • et al.
        Sarcopenia predicts worse postoperative outcomes and decreased survival rates in patients with colorectal cancer: a systematic review and meta-analysis.
        Int J Colorectal Dis. 2021; 36: 1077-1096
        • Sun G.
        • Li Y.
        • Peng Y.
        • et al.
        Can sarcopenia be a predictor of prognosis for patients with non-metastatic colorectal cancer? A systematic review and meta-analysis.
        Int J Colorectal Dis. 2018; 33: 1419-1427
        • Boakye D.
        • Rillmann B.
        • Walter V.
        • et al.
        Impact of comorbidity and frailty on prognosis in colorectal cancer patients: a systematic review and meta-analysis.
        Cancer Treat Rev. 2018; 64: 30-39
        • van Vugt J.L.A.
        • Coebergh van den Braak R.R.J.
        • Lalmahomed Z.S.
        • et al.
        Impact of low skeletal muscle mass and density on short and long-term outcome after resection of stage I-III colorectal cancer.
        Eur J Surg Oncol. 2018; 44: 1354-1360
        • Antoniou G.A.
        • Antoniou S.A.
        • Torella F.
        Editor's choice - endovascular vs. open repair for abdominal aortic aneurysm: systematic review and meta-analysis of updated peri-operative and long-term data of randomised controlled trials.
        Eur J Vasc Endovasc Surg. 2020; 59: 385-397
        • Sousa A.S.
        • Guerra R.S.
        • Fonseca I.
        • et al.
        Sarcopenia and length of hospital stay.
        Eur J Clin Nutr. 2016; 70: 595-601
        • Kou H.W.
        • Yeh C.H.
        • Tsai H.I.
        • et al.
        Sarcopenia is an effective predictor of difficult-to-wean and mortality among critically ill surgical patients.
        PLos One. 2019; 14: e0220699
        • Cadili A.
        • Turnbull R.
        • Malo-Hervas M.
        • et al.
        Identifying patients with AAA with the highest risk following endovascular repair.
        Vasc Endovascular Surg. 2012; 46: 455-459
        • Lu K.
        • Farber A.
        • Schermerhorn M.L.
        • et al.
        The effect of ambulatory status on outcomes of percutaneous vascular interventions and lower extermity bypass for critical limb ischemia in the vascular quality initiative.
        J Vasc Surg. 2017; 65: 1706-1712
        • Rao A.
        • Mehta A.
        • Lazar A.
        • et al.
        Association between ambulatory status and outcomes after open abdominal aortic aneurysm repairs.
        Ann Vasc Surg. 2021;
        • Beaudart C.
        • McCloskey E.
        • Bruyère O.
        • et al.
        Sarcopenia in daily practice: assessment and management.
        BMC Geriatr. 2016; 16: 1-10
        • Robinson S.M.
        • Reginster J.Y.
        • Rizzoli R.
        • et al.
        Does nutrition play a role in the prevention and management of sarcopenia?.
        Clin Nutr. 2018; 37: 1121-1132