The impact of frailty on enhanced recovery protocol compliance and postoperative outcomes after infrainguinal arterial bypass.

Abstract

The aim of this study was to evaluate the impact of frailty on enhanced recovery protocol (ERP) compliance and the impact of ERP on adverse postoperative outcomes in frail patients undergoing infrainguinal arterial bypass. We performed a retrospective single-institution study of patients undergoing infrainguinal arterial bypass (2021-2024). Patients were categorized into three frailty groups using the National Surgical Quality Improvement Program five-item frailty index where F1 is less frail (F1 = 0-1 risk factor; F2 = 2 risk factors; F3 = 3-5 risk factors). The association between frailty and both ERP compliance and postoperative outcomes were analyzed. The χ² and Fisher's exact tests were used for categorical variables while continuous variables were analyzed by Kruskal-Wallis test. Time-to-event outcomes were assessed using Kaplan-Meier survival analysis in the elective intervention cohort, with follow-up truncated at 30 days. We identified 257 patients and stratified them by frailty (F1 = 32.7%; F2 = 36.6%; F3 = 30.7%). F1 patients were significantly younger (mean age, F1 = 65.0 years; F2 = 71.6 years; F3 = 71.6 years; P < .001) and less likely to present with tissue loss (F1 = 31.0%; F2 = 47.9%; F3 = 62.0%; P < .001). ERP compliance was not associated with frailty (F1 = 57.1%; F2 = 54.8%; F3 = 61.5%; P = .739). Overall, patients who underwent ERP had a significantly shorter median postoperative length of stay compared with non-ERP patients (4.8 vs 7.0 days; P < .001). Within the F3 cohort, ERP compliance was associated with a lower reintervention rate (ERP = 15.0% vs non-ERP = 33.3%; P = .050), lower postoperative length of stay (ERP = 7.9 days vs non-ERP = 9.8 days; P = .016), and a decrease in 30-day mortality (ERP = 2.5% vs non-ERP = 7.7%; P = .298). In a time-to-event analysis of elective procedures, no differences were observed in the 30-day freedom from reintervention, readmission, or mortality rates. High frailty was not a barrier to the implementation of an ERP, and an ERP was associated with improved postoperative outcomes in highly frail patients.