Frailty and Vascular Surgery: Age Never Lies

Abstract

“Alas! In the clothes of the greatest potentate, what is there but a man?”(Robert Louis Stevenson, The Suicide Club)1Stevenson R.L. The Suicide Club. London Magazine, London1878Google Scholar By 2050, more than 35% of all European inhabitants will be 60 years of age or older.2Etzioni D.A. Liu J.H. Maggard M.A. Ko C.Y. The aging population and its impact on the surgery workforce.Ann Surg. 2003; 238: 170-177Crossref PubMed Scopus (551) Google Scholar Hence, frailty, defined as multidimensional vulnerability due to age associated decline in physiological reserve, is an impending issue for all surgical disciplines.3Robinson T.N. Wu D.S. Pointer L. Dunn C.L. Cleveland Jr., J.C. Moss M. Simple frailty score predicts postoperative complications across surgical specialties.Am J Surg. 2013; 206: 544-550Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar It appears to be related to adverse outcomes in the short and long term after vascular surgical procedures.4Shinall Jr., M.C. Arya S. Youk A. Varley P. Shah R. Massarweh N.N. et al.Association of preoperative patient frailty and operative stress with postoperative mortality.JAMA Surg. 2019; 13e194620Google Scholar,5Houghton J.S.M. Nickinson A.T.O. Morton A.J. Nduwayo S. Pepper C.J. Rayt H.S. et al.Frailty factors and outcomes in vascular surgery patients: a systematic review and meta-analysis.Ann Surg. 2019; (Epub ahead of print 22 October 2019)https://doi.org/10.1097/SLA.0000000000003642Crossref PubMed Scopus (28) Google Scholar In their present paper, Ambler et al. underline the relevance of frailty for patient outcomes after vascular surgery, namely the treatment of abdominal aortic aneurysms, acute and chronic limb ischaemia, and carotid disease.6Ambler G.K. Kotta P.A. Zielinski L. Kalyanasundaram A. Brooks D.E. Ali A. et al.The effect of frailty on long-term outcomes in vascular surgical patients.Eur J Vasc Endovasc Surg. 2020; 60: 264-272Abstract Full Text Full Text PDF Scopus (9) Google Scholar In their methodologically sound study, the authors evaluated the Addenbrookes Vascular Frailty Score (AVFS) as a promising tool to assess the effect of pre-operative existing frailty on the five year mortality and re-admission rate.7Ambler G.K. Brooks D.E. Al Zuhir N. Ali A. Gohel M.S. Hayes P.D. et al.Effect of frailty on short- and mid-term outcomes in vascular surgical patients.Br J Surg. 2015; 102: 638-645Crossref PubMed Scopus (70) Google Scholar Furthermore, they created an addendum to the AVFS by combining the six established factors: the longer (L)AVFS, which should focus, in particular, on long term outcome. The handy score, based on variables such as haemoglobin <120 g/L, lack of independent mobility, polypharmacy, and emergency admission, can easily be applied in daily practice. According to the findings of Ambler et al.,7Ambler G.K. Brooks D.E. Al Zuhir N. Ali A. Gohel M.S. Hayes P.D. et al.Effect of frailty on short- and mid-term outcomes in vascular surgical patients.Br J Surg. 2015; 102: 638-645Crossref PubMed Scopus (70) Google Scholar patient age, lack of mobility, polypharmacy, and emergency admission were significantly related to mortality over a five year follow up period. The AVFS and the LAVFS were able to stratify patients according to their long term survival and re-admission free survival rates. Regarding the ability to divide patients into different survival groups, the LAVFS seems to be favourable. Finally, both scoring systems could be evaluated as useful and necessary additions to the current treatment guidelines for decision making in elderly patients. Even if some relevant limitations, such as the missing presentation of mortality details and the joint assessment of four different vascular surgical disorders, have to be considered, this study emphasises the need to assess our old and frail patients appropriately. The LAVFS could improve the treatment of older vascular surgical patients by enabling a more accurate patient assessment. Finally, this could help to avoid harmful and possibly unnecessary surgery. The Effect of Frailty on Long Term Outcomes in Vascular Surgical PatientsEuropean Journal of Vascular and Endovascular SurgeryVol. 60Issue 2PreviewFrailty is a multidimensional vulnerability due to age associated decline. The impact of frailty on long term outcomes was assessed in a cohort of vascular surgical patients. Full-Text PDF Open Archive