ObjectiveFrailty has persistently been associated with unfavorable short-term outcomes after vascular surgery, including an increased complication risk, greater readmission rate, and greater short-term mortality. However, a knowledge gap remains concerning the association between preoperative frailty and long-term mortality. In the present study, we aimed to determine this association in elective vascular surgery patients. MethodsThe present study was a part of a large prospective cohort study initiated in 2010 in our tertiary referral teaching hospital to study frailty in elderly elective vascular surgery patients (Vascular Ageing Study). A total of 639 patients with a minimal follow-up of 5 years, who had been treated from 2010 to 2014, were included in the present study. The Groningen Frailty Indicator, a 15-item self-administered questionnaire, was used to determine the presence and degree of frailty. ResultsOf the 639 patients, 183 (28.6%) were considered frail preoperatively. For the frail patients, the actuarial survival after 1, 3, and 5 years was 81.4%, 66.7%, and 55.7%, respectively. For the nonfrail patients, the corresponding survival was 93.6%, 83.3%, and 75.2% (log-rank test, P < .001). Frail patients had a significantly greater risk of 5-year mortality (unadjusted hazard ratio, 2.09; 95% confidence interval, 1.572-2.771; P < .001). After adjusting for surgical- and patient-related risk factors, the hazard ratio was 1.68 (95% confidence interval, 1.231-2.286; P = .001). ConclusionsThe results of our study have shown that preoperative frailty is associated with significantly increased long-term mortality after elective vascular surgery. Knowledge of a patient's preoperative frailty state could, therefore, be helpful in shared decision-making, because it provides more information about the procedural benefits and risks.

Frailty is a clinical syndrome associated with loss of metabolic reserves that is prevalent among patients who present to vascular surgery clinics for evaluation. The clinical frailty scale (CFS) is a rapid assessment method shown to be highly specific for identifying frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to predict loss of independence after major vascular procedures. We identified all patients living independently at home that were prospectively assessed using the CFS before undergoing an elective major vascular surgery procedure (admitted for more than 24 hours) at an academic medical center between January 2016 and January 2017. Patient and procedure-level data were obtained from our institutional Vascular Quality Initiative registry database. The composite outcome of discharge to a skilled nursing facility or 30-day mortality was evaluated using bivariate and multivariate regression models. The CFS was used to assess 75 independent patients before undergoing elective open abdominal aortic aneurysm repair (9%), endovascular aneurysm repair (17%), thoracic endovascular aortic repair (4%), suprainguinal bypass (8%), infrainguinal bypass (19%), carotid endarterectomy (13%), or a peripheral vascular intervention (29%). Among 21 individuals (28%) categorized as being frail using the CFS, there was no significant difference in age, gender, or hospital length of stay (6 days frail vs 4 days nonfrail; P = .15) compared to nonfrail patients. However, frail patients were significantly more likely to need mobility assistance after surgery (67% frail vs 25% nonfrail; P < .01) and to be discharged to a nursing facility or die within 30 days after surgery (33% frail vs 9% nonfrail; P = .01). Preoperative frailty was associated with an over fourfold higher risk (odds ratio, 4.8; 95% confidence interval, 1.1-20.7; P < .05) of 30-day mortality or loss of independence, independent of the vascular procedure undertaken. The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective major vascular surgery and can be used to predict the likelihood of requiring discharge to a nursing facility after surgery. The identification of frail patients before major surgery can help to manage postoperative expectations and optimize transitions of care.

BackgroundWomen have poorer outcomes after vascular surgery as compared to men as shown by studies recently. Frailty is also an independent risk factor for postoperative morbidity and mortality. This study examines the interplay of gender and frailty on outcomes after infrainguinal vascular procedures. Materials and methodsThe American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent infrainguinal vascular procedures from 2005–2012. Frailty was measured using a modified frailty index (mFI; derived from the Canadian Study of Health and Aging). Univariate and multivariate analysis were performed to investigate the association of preoperative frailty and gender, on postoperative outcomes. ResultsOf 24,645 patients (92% open, 8% endovascular), there were 533 deaths (2.2%) and 6198 (25.1%) major complications within 30 d postoperatively. Women were more frail (mean mFI = 0.269) than men (mean mFI = 0.259; P < 0.001). Women and frail patients (mFI>0.25) were more likely to have a major morbidity (P < 0.001) or mortality (P < 0.001) with the highest risk in frail women. On multivariate logistic regression analysis, female gender and increasing mFI were independently significantly associated with mortality (P < 0.05) as well as major complications. The interaction of gender and frailty in multivariate analysis showed the highest adjusted 30-d mortality and morbidity in frail females at 2.8% and 30.1%, respectively and that was significantly higher (P < 0.001) than nonfrail males, nonfrail females and frail males. ConclusionsFemale gender and frailty are both associated with increased risk of complications and death following infrainguinal vascular procedures with the highest risk in frail females. Further studies are needed to explore the mechanisms of interaction of gender and frailty and its effect on long-term outcomes for peripheral vascular disease.

ObjectivesIncreasing numbers of older people are undergoing emergency and elective arterial vascular procedures. Many older patients are frail which is a recognised predictor of adverse postoperative outcomes in other surgical specialties. This study in older patients undergoing arterial vascular surgery examined; the prevalence of preoperative frailty; the clinical feasibility of preoperatively measuring frailty and functional status; the association between these characteristics and adverse postoperative outcome. MethodsProspective observational study in patients aged over 60 years undergoing elective and emergency arterial vascular surgery. Baseline measures of frailty (Edmonton Frail Scale), functional status (gait velocity, timed up and go, hand grip strength) and cognitive function (Montreal Cognitive Assessment) were obtained preoperatively. The primary outcome measure Length of Stay (LOS) and secondary outcome measures of postoperative morbidity (medical and surgical complications), functional status and postoperative in-hospital mortality were recorded. Results125 patients were recruited. Frailty was common in this older surgical population (52% EFS score of ≥6.5) with high frailty scores observed (mean EFS 6.6, SD 3.05) and poor functional status (60% had TUG >15 s, 45% had gait velocity of <0.6 m/s). Higher preoperative EFS (>6.5) was univariately associated with longer LOS (≥12 days), composite measures of postoperative infections, postoperative medical complications and adverse functional outcomes. EFS≥6.5 was predictive of LOS≥12 days, adjusted for age (AUC 0.660, CI 0.541–0.779, p = 0.010). This association between EFS ≥ 6.5 and LOS ≥ 12 days was strengthened with the addition of MoCA < 24 (AUC 0.695, CI 0.584–0.806, p = 0.002). ConclusionsPatients aged over 60 years admitted for arterial vascular surgery were frail, had impaired functional status and were cognitively impaired. This combination of preoperative characteristics was predictive of longer hospital length of stay and associated with adverse postoperative outcome.

BackgroundFrailty in the vascular surgical ward is common and predicts poor surgical outcomes. The aim of this study was to analyze transitions in frailty state in elderly patients after vascular surgery and to evaluate influence of patient characteristics on this transition.MethodsBetween 2014 and 2018, 310 patients, ≥65 years and scheduled for elective vascular surgery, were included in this cohort study. Transition in frailty state between preoperative and follow-up measurement was determined using the Groningen Frailty Indicator (GFI), a validated tool to measure frailty in vascular surgery patients. Frailty is defined as a GFI score ≥4. Patient characteristics leading to a transition in frailty state were analyzed using multivariable Cox regression analysis.ResultsMean age was 72.7 ± 5.2 years, and 74.5% were male. Mean follow-up time was 22.7 ± 9.5 months. At baseline measurement, 79 patients (25.5%) were considered frail. In total, 64 non-frail patients (20.6%) shifted to frail and 29 frail patients (9.4%) to non-frail. Frail patients with a high Charlson Comorbidity Index (HR = 0.329 (CI: 0.133–0.812), p = 0.016) and that underwent a major vascular intervention (HR = 0.365 (CI: 0.154–0.865), p = 0.022) had a significantly higher risk to remain frail after the intervention.ConclusionsThe results of this study, showing that after vascular surgery almost 21% of the non-frail patients become frail, may lead to a more effective shared decision-making process when considering treatment options, by providing more insight in the postoperative frailty course of patients.

Frailty is a state of increased vulnerability and is a stronger predictor for post-operative outcome than age alone. The aim of this study was to determine whether frailty is associated with adverse 30 day outcome in vascular surgery patients. This was a prospective cohort study. All electively operated vascular surgery patients between March 2010 and October 2017 (n=1201), aged≥60 years were evaluated prospectively. Exclusion criteria were arteriovenous access surgery, percutaneous interventions and minor amputations, resulting in 825 patients for further analysis whereas 195 had incomplete data on Groningen Frailty Indicator (GFI) and were excluded. Frailty was measured using the GFI, a screening tool covering 16 items in the domains of functioning. Patients with a total score of ≥4 were classified as frail. The primary outcome parameter was 30 day morbidity (based on the Comprehensive Complication Index). Secondary outcome measures were 30 day mortality, hospital readmission, and type of care facility after discharge. Outcomes were adjusted for sex, body mass index, smoking status, hypertension, Charlson Comorbidity Index, and type of intervention. There was an unequal sex distribution (77.6% male). The mean age was 72.1 years. One hundred and eighty-four patients (22.3%) were considered frail. The mean Comprehensive Complication Index was 8.5. Frail patients had a significantly higher Comprehensive Complication Index (3.7 point increase, p=.005). Patients with impaired cognition and reduced psychosocial condition, two domains of the GFI, had a significantly higher Comprehensive Complication Index. Also, the 30 day mortality rate was higher in frail patients (2.7 point increase; p=.05), and they were discharged to a care facility more often (7.7 point increase; p<.001). There was no significant difference in readmission rates between frail and non-frail patients. Frailty is associated with a higher risk of post-operative complications and discharge to a nursing home after vascular surgery. Some frailty domains (mobility, nutrition, cognition and psychosocial condition) appear to have a more pronounced impact.

Frailty has been established as an important predictor of health-care outcomes. We hypothesized that the use of a modified frailty index would be a predictor of mortality and adverse occurrences in vascular surgery patients. Under the data use agreement of the American College of Surgeons, and with institutional review board (IRB) approval, the National Surgical Quality Improvement Program (NSQIP) Participant Utilization File was accessed for the years 2005-2008 for inpatient vascular surgery patients. Using the Canadian Study of Health and Aging Frailty Index (FI), 11 variables were matched to the NSQIP database. An increase in FI implies increased frailty. The outcomes assessed were mortality, wound infection, and any occurrence. We then compared the effect of FI, age, functional status, relative value units (RVU), American Society of Anesthesiology (ASA) score, and wound status on mortality. Statistical analysis was done using chi-square analysis and stepwise logistic regression. A total of 67,308 patients were identified in the database, 3913 wound occurrences, 6691 infections, 12,847 occurrences of all kinds, and 2800 deaths. As the FI increased, postoperative wound infection, all occurrences, and mortality increased (P < 0.001). Stepwise logistic regression using the FI with the NSQIP variables of age, work RVU, ASA class, wound classification, emergency status, and functional status showed FI to have the highest odds ratio (OR) for mortality (OR = 2.058, P < 0.001). A simplified FI can be obtained by easily identifiable patient characteristics, allowing for accurate prediction of postoperative morbidity and mortality in the vascular surgery population.

Frailty in older vascular surgery patients is associated with increased mortality, hospital stay, and morbidity. The association of frailty with hospital-acquired geriatric syndromes such as delirium and functional decline has not been well studied. To investigate the association between frailty and hospital-acquired geriatric syndromes in older hospitalized vascular surgery patients, and to evaluate the prognostic performance of the frailty index (FI) and the Clinical Frailty Scale (CFS) for delirium and functional decline. Prospective cohort study. Acute care academic hospital. Patients aged 65 years or more admitted to a tertiary vascular surgery unit (N=150). Frailty was assessed using the FI and CFS. The adjusted association of frailty status with delirium and functional decline was assessed using logistic regression analysis. The prognostic performance of FI and CFS was determined by assessing C-statistic and positive and negative predictive values (PPV and NPV). Of 150 participants, FI identified 34 (23%) and CFS identified 45 (30%) as frail. Frailty was an independent predictor of delirium (FI adjusted odds ratio, odds ratio (OR) = 5.66, 95% confidence interval (CI) = 1.53-21.03; CFS adjusted OR = 4.07, 95% CI = 1.14-14.50), but not functional decline. FI and CFS showed acceptable prognostic performance for delirium (C-statistic 0.74), but not functional decline (C-statistic 0.63-0.64). For both outcomes, the FI and CFS had high NPV (86-96%), and low PPV (22-29%). Frail older vascular surgery patients are more likely to develop hospital-acquired geriatric syndromes. The FI and CFS have acceptable prognostic performance for predicting delirium but not all individuals who are identified as frail develop delirium. Ongoing research is needed to identify interventions that improve outcomes in patients who screen positive for frailty.

BackgroundFrailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision‐making about vascular surgery in the resource constrained COVID‐19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes.MethodsThe COVID‐19 Vascular Service in Australia (COVER‐AU) prospective cohort study evaluates 30‐day and six‐month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March–July 2020. The primary outcome was mortality, with secondary outcomes procedure‐related outcomes and hospital utilization. Frailty was assessed using the nine‐point visual Clinical Frailty Score, scores of 5 or more considered frail.ResultsOf the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non‐frail patients (OR 1.68, 95%CI 0.79–3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non‐frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non‐frail patients, after adjustment (OR 2.01; 95% CI 1.17–3.78), driven by a high rate of amputation during the period of reduced surgical activity.ConclusionOur findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.

Frailty is a syndrome where the ability to cope with acute physiological stress is compromised, although it is unclear what impact this stress has on long-term outcomes. Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity is a validated method for calculating levels of stress associated with vascular procedures. We designed this study to evaluate the long-term impact of different levels of surgical stress among frail older patients undergoing vascular surgery procedures. We identified all independently living patients who underwent prospective frailty assessment followed by an elective vascular surgery procedure captured in the Vascular Quality Initiative registry (endovascular abdominal aortic aneurysm [AAA] repair, thoracic endovascular aortic repair, suprainguinal and infrainguinal bypass, peripheral vascular intervention, carotid endarterectomy, and open AAA) at an academic institution between January 2016 and July 2018. Patient- and procedure-level data were obtained from our institutional data warehouse and Vascular Quality Initiative database, and used to calculate Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity scores. The association between frailty and composite outcome of any major complications (surgical site infection; graft thrombectomy; major amputation; adverse cardiac, pulmonary, or neurologic event; acute renal insufficiency; and/or reoperation related to the index procedure), nonhome living status, or death within 1year after low-, medium-, and high-stress vascular procedures was evaluated using bivariate and logistic regression models. A total of 163 patients were identified (70% male, mean age 67.8years) who underwent open AAA repair (6%), endovascular AAA repair (21%), thoracic endovascular aortic repair (7%), suprainguinal bypass (5%), infrainguinal bypass (18%), carotid endarterectomy (18%), or peripheral vascular interventions (25%), which included 44 (27%) patients diagnosed with frailty before surgery. Overall, frail patients had significantly higher rates of the 1-year composite outcome (48% frail versus 27% nonfrail; P=0.012) when compared with nonfrail patients, with a significant dose-dependent effect as the level of stress increased. In comparison, increasing levels of surgical stress had a negligible effect on long-term outcomes among nonfrail patients. The interaction between frailty and high surgical stress was found in adjusted regression models to be a significant predictor of adverse outcomes within 1year after vascular surgery (odds ratio, 3.3; 95% confidence interval, 1.3-8.6; P<0.01). Frail patients who undergo high-stress vascular procedures have a significantly higher rate of complications leading to loss of functional independence and mortality within the year after their surgery. These data suggest that estimates of surgical stress should be incorporated into clinical decision making for frail older patients before and after surgery.