Abstract
Patients undergoing major vascular surgery may have an increased risk of postoperative complications due to poor 'fitness for surgery'. Prehabilitation aims to optimise physical fitness and risk factors before surgery to improve outcomes. The role of exercise-based prehabilitation in vascular surgery is currently unclear. Therefore, the aim of this systematic review was to assess the benefits and harms of preoperative exercise training in adults undergoing elective vascular surgery. We searched MEDLINE, Embase, CINAHL, and CENTRAL databases, trial registries, and forward and backward citations for studies published between January 2008 and April 2021. We included randomised trials that compared patients receiving exercise training with those receiving usual care or no training before vascular surgery. Outcomes included mortality, complications, and health-related quality of life (HRQOL). Three trials with 197 participants were included. All studies involved people undergoing abdominal aortic aneurysm (AAA) repair. Low-certainty evidence could not differentiate between rates of all-cause mortality. Moderate-certainty evidence indicated that postoperative cardiac and renal complications were less likely to occur in people who participated in preoperative exercise training compared with those who did not. Low-certainty evidence also indicated better postoperative HRQOL outcomes in people who undertook prehabilitation. There were no serious exercise-related adverse events. The evidence on preoperative exercise training for AAA patients is promising, but currently insufficiently robust for this intervention to be recommended in clinical guidelines. High-quality trials are needed to establish its clinical and cost-effectiveness. Research is also needed to determine the feasibility and effects of prehabilitation before lower-limb revascularisation. Trial registration: PROSPERO ID: CRD42021245933.
Highlights
Randomised controlled trials (RCTs) and quasi-RCTs of exercise training for adults preparing for elective major vascular surgery that were published between January 1, 2008 and April 26, 2021 and met the inclusion criteria (Table 1) were identified by using our predefined search criteria (S1 Text) within the following databases: MEDLINE (Ovid), Embase (Ovid), CINAHL Complete (EBSCO), CENTRAL
The surgical populations were limited to peripheral artery disease (PAD), abdominal aortic aneurysm (AAA), and carotid artery disease to maintain a focus on vascular procedures for which prehabilitation might be of greater importance
One study provided moderate-certainty evidence that postoperative cardiac and renal complications were less likely to occur in patients with an AAA who participated in preoperative exercise training compared with those who did not
Summary
This systematic review was conducted in accordance with the methods described in the Cochrane Handbook for Systematic Reviews of Interventions v6.2 [19], reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020statement [20], and registered with the International Prospective Register of Systematic Reviews (PROSPERO 2021 CRD42021245933). Randomised controlled trials (RCTs) and quasi-RCTs (such as those that allocate participants to groups based on location of residence or date of assessment) of exercise training for adults (age 18 years) preparing for elective major vascular surgery that were published between January 1, 2008 and April 26, 2021 and met the inclusion criteria (Table 1) were identified by using our predefined search criteria (S1 Text) within the following databases: MEDLINE (Ovid), Embase (Ovid), CINAHL Complete (EBSCO), CENTRAL. The review was restricted to studies published from 2008 onward because that was the year of the earliest study [21] included in previous reviews of exercise training before vascular surgery [22,23]. Relevant studies were sought through screening of trial registries (ClinicalTrials.gov and ICTRP) and forward and backward citations of included studies
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