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Psoas Muscle Area as a Prognostic Factor for Survival in Patients Undergoing EVAR Conversion

Published:September 01, 2022DOI:https://doi.org/10.1016/j.avsg.2022.08.001

      Abstract

      Objective

      EVAR conversion(EVAR-c) is increasingly reported and known to be technically complex and physiologically demanding. It has been proposed that pragmatic anthropomorphic measures such as psoas muscle area(PMA) may reliably quantify levels of preoperative frailty and be used to inform point of care clinical decision making and patient discussions for a variety of complex operations. To date, there is mixed data supporting use of PMA as a prognostic factor in fenestrated endovascular and open AAA repairs; however, no literature exists evaluating the impact of preoperative PMA on EVAR-c results. Therefore, the purpose of this study was to review our EVAR-c experience and evaluate the association of PMA with perioperative and long-term mortality outcomes.

      Methods

      A retrospective single-center review of all AAA repairs was performed(2002-2019) and EVAR-c procedures were subsequently analyzed(n=153). Cross-sectional PMA at the mid-body of the L3 vertebrae was measured. The lowest PMA tertile was used as a threshold value to designate patients as having “low” PMA(n=51) and this cohort was subsequently compared to subjects with “normal” PMA(n=102). Cox proportional hazards modeling was used to estimate covariate association with all-cause mortality.

      Results

      Patients with low PMA were older(77 vs. 72 years;p=.002), more likely to be female(27% vs. 5%;p<.001), and had reduced BMI(26 vs. 29kg/m2;p=.002). Time to conversion, total number of EVAR reinterventions prior to conversion and elective EVAR-c presentation incidence were similar; however, patients with low PMA had larger aneurysms(8.3 vs. 7.5cm;p=.01) and increased post-EVAR sac growth(2.3 vs. 1cm;p=.005). Unadjusted inpatient mortality was significantly greater for low PMA patients(16% vs. normal PMA, 5%, p=.02). Similarly, the total number of complications was higher among low PMA subjects(1.5±1.9 vs. normal PMA, 0.9±1.5;p=.02). Although frequency of major adverse cardiovascular events and new onset inpatient hemodialysis were similar, low PMA patients had a more than four-fold increased likelihood of having persistent requirement of hemodialysis at discharge(18% vs. 4%,p=.01). The low PMA group had decreased survival at 1 and 5 years, respectively(77±5%, 65±6% vs. normal PMA, 86±3%, 82%±5%;log-rank p=.03). Low PMA was an independent predictor of mortality with every 100mm2 increase in PMA being associated with a 15% reduction in mortality(HR 0.85,95% CI, .74-.97;p=.02).

      Conclusion

      Among EVAR-c patients, subjects with low preoperative PMA had higher rates of postoperative complications and worse overall survival. PMA assessments may be a useful adjunct to supplement traditional risk-stratification strategies when patients are being considered for EVAR-c.
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      References

        • Dua A.
        • Kuy S.
        • Lee C.J.
        • et al.
        Epidemiology of aortic aneurysm repair in the United States from 2000 to 2010.
        J Vasc Surg. 2014; 59: 1512-1517https://doi.org/10.1016/j.jvs.2014.01.007
        • Wanken Z.J.
        • Barnes J.A.
        • Trooboff S.W.
        • et al.
        A systematic review and meta-analysis of long-term reintervention after endovascular abdominal aortic aneurysm repair.
        J Vasc Surg. 2020; 72: 1122-1131https://doi.org/10.1016/j.jvs.2020.02.030
        • de Guerre L.E.V.M.
        • Dansey K.
        • Li C.
        • et al.
        Late outcomes after endovascular and open repair of large abdominal aortic aneurysms.
        J Vasc Surg. 2021; 74: 1152-1160https://doi.org/10.1016/j.jvs.2021.02.024
        • Ultee K.H.
        • Soden P.A.
        • Zettervall S.L.
        • et al.
        Conversion from endovascular to open abdominal aortic aneurysm repair.
        J Vasc Surg. 2016; 64: 76-82https://doi.org/10.1016/j.jvs.2015.12.055
        • Mohapatra A.
        • Robinson D.
        • Malak O.
        • et al.
        Increasing use of open conversion for late complications after endovascular aortic aneurysm repair.
        J Vasc Surg. 2019; 69: 1766-1775https://doi.org/10.1016/j.jvs.2018.09.049
        • Jacobs C.R.
        • Scali S.T.
        • Khan T.
        • et al.
        Endovascular aneurysm repair conversion is an increasingly common indication for open abdominal aortic aneurysm repair.
        J Vasc Surg. 2022; 75: 144-152.e1https://doi.org/10.1016/j.jvs.2021.07.121
        • Kansal V.
        • Nagpal S.
        • Jetty P.
        Editor's Choice - Late Open Surgical Conversion after Endovascular Abdominal Aortic Aneurysm Repair.
        Eur J Vasc Endovasc Surg. 2018; 55: 163-169https://doi.org/10.1016/j.ejvs.2017.10.011
        • Rinaldi E.
        • Kahlberg A.
        • Carta N.
        • et al.
        Late Open Conversion Following Failure of EVAR and TEVAR: "State of the Art".
        Cardiovasc Intervent Radiol. 2020; 43: 1855-1864https://doi.org/10.1007/s00270-020-02636-w
        • Lee D.U.
        • Hastie D.J.
        • Fan G.H.
        • et al.
        Clinical frailty is a risk factor of adverse outcomes in patients with esophageal cancer undergoing esophagectomy: analysis of 2011-2017 US hospitals.
        Dis Esophagus. 2022; ([published online ahead of print, 2022 Jan 25]) (doac002)https://doi.org/10.1093/dote/doac002
        • Levi S.T.
        • Gough B.L.
        • Darcy C.E.
        • et al.
        Pancreatic resections: 30 and 90-day outcomes in octogenarians.
        Surg Oncol. 2021; 37101319https://doi.org/10.1016/j.suronc.2020.01.002
        • Al Abbas A.I.
        • Borrebach J.D.
        • Pitt H.A.
        • et al.
        Development of a Novel Pancreatoduodenectomy-Specific Risk Calculator: an Analysis of 10,000 Patients.
        J Gastrointest Surg. 2021; 25: 1503-1511https://doi.org/10.1007/s11605-020-04725-0
        • Park M.G.
        • Haro G.
        • Mabeza R.M.
        • et al.
        Association of frailty with clinical and financial outcomes of esophagectomy hospitalizations in the United States.
        Surg Open Sci. 2022; 9 (Published 2022 May 19): 80-85https://doi.org/10.1016/j.sopen.2022.05.003
        • Mezzetto L.
        • D'Oria M.
        • Mani K.
        • et al.
        Scoping review of radiological assessment and prognostic impact of skeletal muscle sarcopenia in patients undergoing endovascular repair for aortic disease [published online ahead of print, 2022 Jun 3].
        J Vasc Surg. 2022; S0741-5214 (01603-2)https://doi.org/10.1016/j.jvs.2022.05.005
        • Weerink L.B.M.
        • van der Hoorn A.
        • van Leeuwen B.L.
        • et al.
        Low skeletal muscle mass and postoperative morbidity in surgical oncology: a systematic review and meta-analysis.
        J Cachexia Sarcopenia Muscle. 2020; 11: 636-649https://doi.org/10.1002/jcsm.12529
        • 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: 412-423https://doi.org/10.1093/ageing/afq034
        • Sheetz K.H.
        • Zhao L.
        • Holcombe S.A.
        • et al.
        Decreased core muscle size is associated with worse patient survival following esophagectomy for cancer.
        Dis Esophagus. 2013; 26: 716-722https://doi.org/10.1111/dote.12020
        • 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.e1https://doi.org/10.1016/j.jvs.2020.08.141
        • 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: 764-769https://doi.org/10.1016/j.ejvs.2016.09.011
        • Houghton J.S.M.
        • Nickinson A.T.O.
        • Morton A.J.
        • et al.
        Frailty Factors and Outcomes in Vascular Surgery Patients: A Systematic Review and Meta-analysis.
        Ann Surg. 2020; 272: 266-276https://doi.org/10.1097/SLA.0000000000003642
        • 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 (e2): 2-77https://doi.org/10.1016/j.jvs.2017.10.044
        • Indrakusuma 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: 83-91https://doi.org/10.1016/j.ejvs.2017.10.007
        • Collins J.
        • Noble S.
        • Chester J.
        • Coles B.
        • Byrne A.
        The assessment and impact of sarcopenia in lung cancer: a systematic literature review.
        BMJ Open. 2014; 4 (Published 2014 Jan 2)e003697https://doi.org/10.1136/bmjopen-2013-003697
        • Aubrey J.
        • Esfandiari N.
        • Baracos V.E.
        • et al.
        Measurement of skeletal muscle radiation attenuation and basis of its biological variation.
        Acta Physiol (Oxf). 2014; 210: 489-497https://doi.org/10.1111/apha.12224
        • Filiberto A.C.
        • Scali S.T.
        • Patterson S.
        • et al.
        Treatment and Outcomes of Aortic Graft Infections Using a Decision Algorithm.
        Ann Vasc Surg. 2021; 76: 254-268https://doi.org/10.1016/j.avsg.2021.04.047
        • Scali S.T.
        • Beck A.W.
        • Chang C.K.
        • et al.
        Defining risk and identifying predictors of mortality for open conversion after endovascular aortic aneurysm repair.
        J Vasc Surg. 2016; 63: 873-881.e1https://doi.org/10.1016/j.jvs.2015.09.058
        • Paajanen P.
        • Lindström I.
        • Oksala N.
        • et al.
        Radiographically quantified sarcopenia and traditional cardiovascular risk assessment in predicting long-term mortality after endovascular aortic repair [published online ahead of print, 2022 Mar 31].
        J Vasc Surg. 2022; S0741-5214 (01353-2)https://doi.org/10.1016/j.jvs.2022.03.859
        • George E.L.
        • Arya S.
        • Ho V.T.
        • et al.
        Trends in annual open abdominal aortic surgical volumes for vascular trainees compared to annual national volumes in the endovascular era [published online ahead of print, 2022 May 19].
        J Vasc Surg. 2022; S0741-5214 (01583-X)
        • Dua A.
        • Koprowski S.
        • Upchurch G.
        • Lee C.J.
        • Desai S.S.
        Progressive shortfall in open aneurysm experience for vascular surgery trainees with the impact of fenestrated and branched endovascular technology.
        J Vasc Surg. 2017; 65: 257-261https://doi.org/10.1016/j.jvs.2016.08.075
        • Cesari M.
        • Leeuwenburgh C.
        • Lauretani F.
        • et al.
        Frailty syndrome and skeletal muscle: results from the Invecchiare in Chianti study.
        Am J Clin Nutr. 2006; 83: 1142-1148https://doi.org/10.1093/ajcn/83.5.1142
        • Frisoli Jr., A.
        • Chaves P.H.
        • Ingham S.J.
        • et al.
        Severe osteopenia and osteoporosis, sarcopenia, and frailty status in community-dwelling older women: results from the Women's Health and Aging Study (WHAS) II.
        Bone. 2011; 48: 952-957https://doi.org/10.1016/j.bone.2010.12.025
        • Antoniou G.A.
        • Rojoa D.
        • Antoniou S.A.
        • et al.
        Effect of Low Skeletal Muscle Mass on Post-operative Survival of Patients With Abdominal Aortic Aneurysm: A Prognostic Factor Review and Meta-Analysis of Time-to-Event Data.
        Eur J Vasc Endovasc Surg. 2019; 58: 190-198https://doi.org/10.1016/j.ejvs.2019.03.020
        • Lee J.S.
        • He K.
        • Harbaugh C.M.
        • et al.
        Frailty, core muscle size, and mortality in patients undergoing open abdominal aortic aneurysm repair.
        J Vasc Surg. 2011; 53: 912-917https://doi.org/10.1016/j.jvs.2010.10.111
        • 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: 367-374https://doi.org/10.1002/bjs.11074
        • Heard R.
        • Black D.
        • Ramsay G.
        • et al.
        The prevalence of sarcopaenia in a vascular surgical patient cohort and its impact on outcome.
        Surgeon. 2018; 16: 325-332https://doi.org/10.1016/j.surge.2018.03.001