Association between Peri-operative Sarcopenia and Long Term Survival following Fenestrated Endovascular Aortic Repair for Complex Abdominal Aortic Aneurysm.

Abstract

Sarcopenia, defined as loss of skeletal muscle mass and function, predicts adverse surgical outcomes. This study evaluated longitudinal changes in sarcopenia following fenestrated endovascular aortic repair (FEVAR) and their impact on outcomes. This retrospective, single centre study included patients who underwent FEVAR for complex abdominal aortic aneurysms between 2007 and 2022. Sarcopenia was defined using skeletal muscle area (SMA) cutoffs of < 144 cm² for men and < 92 cm² for women, measured from computed tomography scans. The primary outcome was all cause death; secondary outcomes included longitudinal changes in SMA, analysed with mixed effects models. The study included 169 patients (median age 74.7 years; 87.6% men) with median follow up of 4.8 years. The pre-operative sarcopenia prevalence was 20.7% (n = 35), which increased to 32.5% (n = 55) post-operatively, with significant muscle loss (-6.6 ± 7.2%; p < .001). Subsequently, sarcopenia rates gradually declined to ∼27% over 3 years (1 year: -3.3 ± 9.2%, p < .001; 2 years: -3.7 ± 8.4%, p < .001; 3 years: -3.8 ± 10.7%, p = .006). Pre-operative sarcopenia did not impact 30 day outcomes or overall survival compared with non-sarcopenic patients at these time points (1 year: 88.4% vs. 95.2%; 3 years: 76.7% vs. 78.6%; 5 years: 55.8% vs. 61.9%, p = .090). Conversely, new or worsened post-FEVAR sarcopenia was associated with poorer survival (1 year: 90.6% vs. 95.2%; 3 years: 73.4% vs. 81.0%; 5 years: 53.1% vs. 64.8%; 7 years: 25.5% vs. 47.4%; 10 years: 2.1% vs. 15.5%, p = .001). Post-operative sarcopenia was a stronger predictor of overall mortality (hazard ratio [HR] 2.00, 95% confidence interval [CI] 1.30 - 3.10; p = .002) compared with pre-operative sarcopenia (HR 1.76, 95% CI 1.06 - 2.93; p = .030). In multivariable analysis, only post-operative sarcopenia remained significant (HR 1.89, 95% CI 1.18 - 3.04; p = .009) and was associated with higher seven (74.5% vs. 52.6%; p = .020) and ten year mortality rates (97.9% vs. 84.5%; p = .035). In this retrospective observational study, post-operative skeletal muscle loss following FEVAR was significant and was associated with long term death. This suggests that FEVAR carries a physiological burden warranting careful post-operative assessment and optimisation. Prospective multicentre studies are needed to establish mechanistic pathways and to determine whether interventions improve outcomes.