Preoperative frailty is associated with a significantly increased long-term mortality after elective vascular surgery. This is the conclusion of Louise BD Banning (University of Groningen and University Medical Center Groningen, Groningen, The Netherlands) and colleagues in an online Journal of Vascular Surgery (JVS) article. Based on this main finding, they suggest that “knowledge about a patient’s preoperative frailty state could be helpful in shared decision-making, since it provides more information about the procedural benefits and risks”.
Banning et al write that frailty has been associated with “unfavourable short-term outcomes” after vascular surgery, including increased risk of complication, higher readmission rate, and higher short-term mortality. In this study, they aimed to determine the association between preoperative frailty and long-term mortality in elective vascular patients, a connection for which there is currently a lack of knowledge, the authors state.
The present investigation is part of the larger Vascular Ageing Study—a large, prospective cohort study initiated in 2010 at the investigators’ centre (a tertiary referral teaching hospital) to assess frailty in elderly elective vascular surgery patients—Banning and colleagues relay.
In this substudy, they included 639 patients, all of whom had a minimum follow-up of five years and were treated between 2010 and 2014. The investigators communicated that they used the Groningen Frailty Indicator—a 15-item self-administered questionnaire—to determine the presence and degree of frailty.
Writing in JVS, Banning et al report that in 183 patients (28.6%) who were considered frail preoperatively, the actuarial survival after one, three, and five years was 81.4%, 66.7%, and 55.7%, respectively. For non-frail patients, the figures were 93.6%, 83.3%, and 75.2%, respectively (log-rank test p<0.001).
They add that frail patients had a “significantly higher risk of five-year mortality”—with an unadjusted hazard ratio (HR) of 2.09 (95% confidence interval [CI], 1.572–2.771; p<0.001). After adjusting for surgical and patient-related risk factors, the authors detail that the HR was 1.68 (95% CI, 1.343–2.453; p=0.001).
In the discussion of their findings, Banning and colleagues emphasise the strength of their conclusion that preoperative frailty is associated with shortened long-term survival. They note: “Even after adjusting for covariates like age and comorbidities, the risk for five-year mortality remained almost twice as high for frail patients.”
They write that these results “highlight the importance of implementing a standard, preoperative frailty assessment tool in vascular surgery, in order to optimise the preoperative risk prediction and potentially intervene in causal domains of frailty”. Prehabilitation, with attention for physician, nutritional, and cognitive improvement, they suggest “has the potential to tackle these domains and thus speed up recovery or prevent further deterioration”.