title: Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.
abstract: BACKGROUND
  Frailty, defined as a biologic syndrome of decreased reserve and resistance 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). The primary outcome was 30-day mortality, and secondary outcomes included 30-day morbidity and FTR. The effect of frailty on outcomes was assessed by multivariate regression analysis, adjusted for age, American Society of Anesthesiology (ASA) class, and significant comorbidities.
  
  
  RESULTS
  Of 23,207 patients, 339 (1.5% overall; 1.0% EVAR and 3.0% OAR) died ≤30 days of repair. One or more complications occurred in 2567 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 frailty score were 1.9 (95% confidence interval [CI], 1.2-3.0) after EVAR and 2.3 (95% CI, 1.4-3.7) after OAR. Similarly, compared with the least frail, the most frail patients were significantly more likely to experience severe (Clavien-Dindo class IV) complications after EVAR (OR, 1.7; 95% CI, 1.3-2.1) and OAR (OR, 1.8; 95%, CI, 1.5-2.1). There was also a higher FTR rate among frail patients, with 1.7-fold higher risk odds of mortality (95% CI, 1.2-2.5) in the highest tertile of frailty compared with the lowest when postoperative complications occurred.
  
  
  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 postoperative complications. Preoperative recognition of frailty may serve as a useful adjunct for risk assessment.
authors.affiliation: Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Ga; Atlanta Veterans Affairs Medical Center, Decatur, Ga. Electronic address: shipra.arya@emory.edu.
authors.forename: Shipra
authors.initials: S
authors.lastname: Arya
authors.affiliation: Emory University Rollins School of Public Health, Atlanta, Ga.
authors.forename: Sung In
authors.initials: SI
authors.lastname: Kim
authors.affiliation: Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Ga.
authors.forename: Yazan
authors.initials: Y
authors.lastname: Duwayri
authors.affiliation: Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Ga; Atlanta Veterans Affairs Medical Center, Decatur, Ga.
authors.forename: Luke P
authors.initials: LP
authors.lastname: Brewster
authors.affiliation: Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Ga.
authors.forename: Ravi
authors.initials: R
authors.lastname: Veeraswamy
authors.affiliation: Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Ga; Atlanta Veterans Affairs Medical Center, Decatur, Ga.
authors.forename: Atef
authors.initials: A
authors.lastname: Salam
authors.affiliation: Division of Vascular Surgery, Emory University School of Medicine, Atlanta, Ga.
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Dodson
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D002170:Canada / Q000453:epidemiology; D016009:Chi-Square Distribution; D015897:Comorbidity; D016208:Databases, Factual; D017558:Elective Surgical Procedures; D005260:Female; D006304:Health Status; D006305:Health Status Indicators; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000401:mortality