Clinical frailty predicts long-term survival and return to functional status following fenestrated and branched aortic repair for thoracoabdominal aortic aneurysm.

Abstract

Prior studies have demonstrated that frailty, characterized by a patient's burden of chronic medical comorbidities, is predictive of adverse outcomes across surgical specialties. This study uses the clinical frailty score (CFS) to assess the impact of phenotypic frailty on long-term mortality and return to preoperative functional status (RFS) following fenestrated and branched endovascular repair (F/BEVAR) for thoracoabdominal aortic aneurysm (TAAA). All patients enrolled in a prospective, physician-sponsored investigational device exemption clinical trial from 2012 to 2023 following F/BEVAR for TAAA were included. Patients were assigned to a standard or high-risk category, if they had one or more of the following criteria: CFS ≥4, metabolic equivalent of ≤2, prior spinal cord injury or stroke, CHF, chronic obstructive pulmonary disease (COPD) with oxygen requirement, chronic kidney disease (CKD) stage IV or V, peripheral artery disease, active cancer with life expectancy of more than 1 year, heavy aortic atheroma burden, history of cirrhosis, and/or substance use disorder. Long-term survival and RFS were assessed using Kaplan-Meier analysis and Cox regression analysis based on high-risk status. A secondary survival analysis based on CFS (CFS ≥4 and <4) was performed with adjustment for age, sex, congestive heart failure, COPD with oxygen requirement, CKD stage IV/V. 213 patients underwent F/BEVAR, including 96 standard-risk (45%) and 117 high-risk patients (55%). Other than high-risk classifiers, there were no differences in comorbidities, operative presentation, or maximum aneurysm diameter. Within the high-risk study cohort, a total of 57 patients had a CFS of ≥4 (48.7%), 49 patients had CKD stage IV/V (41.9%), and 33 patients had a metabolic equivalent of <2 (28.2%). Higher CFS (hazard ratio [HR], 1.37; 95% CI, 1.07-1.74), lower body mass index (HR, 0.87; 95% CI, 0.82-0.99), larger aneurysm size (HR, 1.03; 95% CI, 1.01-1.05), COPD with oxygen requirement (HR, 2.64; 95% CI, 1.62-4.30), and CKD stage IV or V (HR, 2.85; 95% CI, 1.29-6.28) were associated with reduced long-term survival in multivariable analysis. Standard-risk patients were more likely to RFS (92.7% vs 68.4%; P < .01), whereas a higher CFS (odds ratio [OR], 0.49; 95% CI, 0.34-0.72) and COPD with oxygen requirement (OR, 0.42; 95% CI, 0.20-0.88) were associated with a lower likelihood of RFS. High-risk patients had lower survival at 1 year (76% vs 95%) and 5 years (39% vs 58%; P < .01). When stratified by CFS, differences in survival persisted. Patients with CFS of ≥4 also had reduced survival at 1 year (70% vs 90%) and 5 years (33% vs 53%; P = .01), respectively. Patients with a higher CFS have worse long-term survival and are less likely to RFS, even after adjustment for medical comorbidities. Given these findings, the identification of high-risk patients, including direct measurement of phenotypic frailty using the clinical frailty scale is an important tool for preoperative risk stratification and patient selection for F/BEVAR.