The Impact of Body Composition on Mortality and Hospital Length of Stay after Endovascular and Open Aortic Aneurysm Repair: A Retrospective Cohort Study.

Abstract

Background: Sarcopenia is an indicator of preoperative frailty and a patient-specific risk factor for poor prognosis in elderly surgical patients. Some studies have explored the prognostic significance of body composition parameters in relation to perioperative mortality after aortic repair and to mid- and long-term survival following endovascular aneurysm repair (EVAR). This study aimed to comprehensively investigate the effects of various body composition parameters, including but not limited to sarcopenia, on short- and long-term mortality as well as the length of hospital stay in two large cohorts of patients undergoing open surgical aortic repair (OSR) or EVAR. Methods: A single-institution retrospective cohort study included patients who underwent EVAR or OSR from January 2010 to December 2017. Several parameters of body composition on axial CT angiography images were analyzed, such as skeletal muscle area (SMA) with derived skeletal muscle index (SMI), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Results: 477 patients were included: 250 treated by OSR and 227 by EVAR; the mean age was 70.8 years (OSR) and 76.3 years (EVAR), with a mean follow-up of 54 months. Sarcopenia was associated with a prolonged length of hospital stay in EVAR patients but not in OSR patients (β coefficient 3.22; p-value 0.022 vs. β coefficient 0.391; p-value 0.696). Sarcopenia was an elevated one-year mortality risk post-EVAR compared to those without sarcopenia (p-value for the log-rank test 0.05). SMA and SMI were associated with long-term mortality in EVAR patients even after adjusting for multiple confounders (HR 0.98, p-value 0.003; HR 0.97, p-value 0.032). The analysis of the OSR cohort did not show a significant correlation between short- and long-term mortality and sarcopenia indicators. Conclusions: The results suggest that body composition could predict increased mortality and longer hospital stays in patients undergoing EVAR procedures. These findings were not confirmed in the cohort of patients who underwent OSR. Patients with sarcopenia and pre-operative malnutrition should be critically assessed to define the indication for treatment in this predominantly elderly and morbid cohort, despite EVAR procedures being less invasive. Body composition evaluation is an inexpensive and reproducible tool that can contribute to an improved decision-making process by identifying patients who will benefit most from EVAR, ensuring a more personalized and cost-effective treatment strategy. Further studies are planned to explore the added value of integrating body composition into a comprehensive risk stratification before aortic surgery.