Frailty Increases the Risk of 30-day Mortality and Morbidity after Elective Abdominal Aortic Aneurysm Repair Independent of Age and Comorbidities Open Access

Abstract

Background: Frailty, defined as a biologic syndrome of increased vulnerability to stressors, has been linked to adverse outcomes after surgery. We evaluated the effect of frailty on 30-day mortality, morbidity, and failure to rescue (FTR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair.

Methods: Patients undergoing elective endovascular AAA repair (EVAR) or open AAA repair (OAR) were identified in the National Surgical Quality Improvement Program database for the years 2005 to 2012. Frailty was assessed using the modified frailty index (mFI) derived from the Canadian Study of Health and Aging (CSHA), which was categorized into tertiles (low, middle, and high). The primary outcome was 30-day mortality. In addition, post-operative morbidity and the contribution of FTR on mortality were evaluated. The effect of frailty on outcomes was assessed by multivariate regression analysis, which was adjusted for age, American Society of Anesthesiology (ASA) class, and co-morbidities.

Results: Of 23,207 patients, 339 (1.5% overall; 1.0% EVAR and 3.0% OAR) died within 30 days of repair. One or more complications occurred in 2,567 patients (11.2% overall; 7.8% EVAR and 22.1% OAR). Odds ratios (ORs) for mortality adjusted for age, ASA class, and other comorbidities in the group with the highest v. lowest frailty tertiles were 1.9 [95% confidence interval (CI), 1.2-3.0] and OAR (OR, 1.8; 95% CI, 1.5-2.1). There was also a higher FTR rate when post-operative complications occurred, with 1.7-fold higher odds of mortality (95% CI, 1.2-2.5) in the highest tertile of frailty compared with the lowest.

Conclusions: Higher mFI, independent of other risk factors, is associated with higher mortality and morbidity in patients undergoing elective EVAR and OAR. The mortality in frail patients is further driven by FTR from post-operative complications. Frailty evaluation may serve as a useful adjunct for pre-operative risk assessment.

Table of Contents

Background. 1

Methods. 4

Results. 8

Discussion. 12

Summary. 15

Public Health Implications. 16

Future Directions. 17

References. 18

Tables. 21

Figures. 26

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Global Epidemiology - MPH & MSPH
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Medicine and Surgery
Keyword	frailty modified frailty index abdominal aortic aneurysm vascular surgery risk assessment elective surgery
Committee Chair / Thesis Advisor	Patzer, Rachel Elizabeth, Emory University
Committee Members	Arya, Shipra , Emory University

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