Heart Center, Kuopio University Hospital, Kuopio, Finland.
Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston, TX.
J Vasc Surg. 2022 Nov;76(5):1170-1179.e2. doi: 10.1016/j.jvs.2022.05.008. Epub 2022 Jun 11.
In the present study, we assessed the effects of patient frailty status on the early outcomes and late survival after fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal and thoracoabdominal aortic aneurysms.
We retrospectively reviewed the clinical data and outcomes of consecutive patients who had undergone elective FB-EVAR from 2007 to 2019 in a single institution. A previously validated 11-item modified frailty index (mFI-11) was derived from the comorbidity and preoperative functional status data. An mFI-11 <0.3 was defined as low risk, 0.3 to 0.5 as medium risk, and >0.5 as high risk. The studied outcomes were 90-day mortality, major adverse events (MAE), and long-term survival. Multivariate analyses were performed to identify the independent predictors of these outcomes.
A total of 592 patients (155 women, mean age, 75 ± 8 years) had undergone FB-EVAR. Using the mFI-11, 310 patients (52%) were included in the low-risk, 199 (34%) in the medium-risk, and 83 (14%) in the high-risk group. The 90-day mortality was significantly higher in the high-risk group than in the medium- and low-risk groups (13%, 4%, and 3%, respectively; P < .01). The corresponding MAE rates were 27%, 18%, and 19% (P = .23). As a subgroup, 44 patients in the high-risk group had had chronic kidney disease (CKD). The 90-day mortality for these patients was as high as 23%, and 32% had experienced MAE. On multivariable analysis, the independent risk factors for 90-day mortality were CKD, respiratory disease, and a high mFI-11. The independent risk factors for MAE were female sex, CKD, larger aneurysm diameter, and the high-risk subgroup with CKD. The independent risk factors for long-term mortality were age, a low body mass index, CKD, larger aneurysm diameter, extent I-III thoracoabdominal aortic aneurysm, respiratory disease, congestive heart failure, a history of cerebrovascular problems, and higher mFI-11. The estimated survival at 1 year was 91% ± 2% in the low-risk, 88% ± 2% in the medium-risk, and 78% ± 5% in the high-risk group (P < .001). The corresponding 5-year survival estimates were 60% ± 4%, 52% ± 5%, and 32% ± 6%. The mean follow-up time was 2.9 ± 2.3 years. The patients treated during the first quartile of the study period were significantly more frail than were those in the later quartiles. Also, the outcomes of FB-EVAR had improved over time.
Greater frailty was significantly associated with early mortality. Together with CKD, frailty was also associated with MAE and lower patient survival after FB-EVAR. The mFI-11 represents the accumulation of comorbidities and can be used to assist in better patient selection for FB-EVAR.
本研究旨在评估患者脆弱状况对复杂腹主动脉瘤和胸腹主动脉瘤腔内修复术后（FB-EVAR）早期结果和晚期生存的影响。
我们回顾性分析了 2007 年至 2019 年在一家医疗机构接受择期 FB-EVAR 的连续患者的临床数据和结局。从合并症和术前功能状态数据中得出了一个经过验证的 11 项改良脆弱指数（mFI-11）。mFI-11<0.3 定义为低危，0.3 至 0.5 为中危，>0.5 为高危。研究结果为 90 天死亡率、主要不良事件（MAE）和长期生存率。采用多变量分析确定这些结果的独立预测因素。
共 592 例患者（155 例女性，平均年龄 75±8 岁）接受了 FB-EVAR。使用 mFI-11，310 例患者（52%）被归入低危组，199 例（34%）归入中危组，83 例（14%）归入高危组。高危组的 90 天死亡率明显高于中危组和低危组（分别为 13%、4%和 3%；P<0.01）。相应的 MAE 发生率分别为 27%、18%和 19%（P=0.23）。作为一个亚组，高危组中有 44 例患者患有慢性肾脏病（CKD）。这些患者的 90 天死亡率高达 23%，32%发生了 MAE。多变量分析显示，90 天死亡率的独立危险因素是 CKD、呼吸疾病和高 mFI-11。MAE 的独立危险因素是女性、CKD、更大的动脉瘤直径和 CKD 高危亚组。长期死亡率的独立危险因素是年龄、低体重指数、CKD、更大的动脉瘤直径、I-III 型胸腹主动脉瘤、呼吸疾病、充血性心力衰竭、脑血管问题史和更高的 mFI-11。低危组、中危组和高危组的 1 年估计生存率分别为 91%±2%、88%±2%和 78%±5%（P<0.001）。相应的 5 年生存率估计分别为 60%±4%、52%±5%和 32%±6%。平均随访时间为 2.9±2.3 年。研究期间前四分之一时间接受治疗的患者明显比后四分之一时间接受治疗的患者脆弱。此外，FB-EVAR 的治疗效果随着时间的推移而改善。
脆弱程度显著与早期死亡率相关。脆弱加上 CKD 与 FB-EVAR 后的 MAE 和较低的患者生存率相关。mFI-11 代表了合并症的积累，可用于协助更好地选择 FB-EVAR 患者。
