Impact of Frailty on Postoperative Outcomes in Patients Undergoing TransCarotid Artery Revascularization (TCAR).

Background: Frailty is a clinical syndrome characterized by a reduction in metabolic reserves leading to increased susceptibility to adverse outcomes following invasive surgical interventions. The 5-item modified frailty index (mFI-5) validated in prior studies has shown high predictive accuracy for all surgical specialties, including vascular procedures. In this study, we aim to utilize the mFI-5 to predict outcomes in Transcarotid Revascularization (TCAR).

Methods: All patients who underwent TCAR from November 2016 to April 2021 in the Vascular Quality Initiative (VQI) Database were included. The mFI-5 was calculated as a cumulative score divided by 5 with 1 point each for poor functional status, presence of diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and hypertension. Patients were stratified into two groups based on prior studies: low mFI-5 (0.6) and high (≥0.6). Primary outcomes included in-hospital death, extended length of postoperative stay (>1 day), and nonhome discharge. Secondary outcomes included in-hospital stroke, transient ischemic attack (TIA), myocardial infarction (MI), a composite endpoint of stroke/death, stroke/TIA, and stroke/death/MI. Univariate and multivariable logistic regression were used to assess the association between mFI-5 and postoperative outcomes. Secondary analysis stratified by symptomatic status was performed.

Results: Out of the 17,983 patients who underwent TCAR, 4526(25.2%) had mFI-5 score of ≥0.6 and considered clinically frail. Compared to the nonfrail group, frail patients were more likely to be female (38.7% vs. 35.6%, P < 0.001), have poor functional status (43.6 vs. 8.3%, P < 0.001), and present with significant comorbidities, including diabetes (75.3% vs. 26.1%, P < 0.001), hypertension (98.9% vs. 88.5%, P < 0.001), CHF (52.2% vs. 5.6, P < 0.001), and COPD (60.3% vs. 14.2%, P < 0.001). They were also more likely to be active smokers (25.4% vs. 20.4%, P < 0.001) and symptomatic prior to intervention (28.7% vs. 25.3%, P < 0.001). On univariate analysis, frail patients were at significantly higher risk to experience adverse outcomes, including in-hospital mortality, TIA, MI, stroke/death, stroke/TIA, stroke/death/MI, discharge to nonhome facility, and extended LOS. After adjusting for potential confounders, frail patients remained at significantly higher risk of in-hospital mortality [aOR 2.26(1.41,3.61), P = 0.001], TIA [aOR 1.65(1.08, 2.54), P = 0.040], nonhome discharge [aOR 1.99(1.71,2.32) P < 0.001], and extended LOS [aOR 1.41(1.27, 1.55) P < 0.001]. On further stratified analysis based on symptomatic status, the increased risk of stroke/death, TIA, and death was observed only in symptomatic patients.

Conclusions: Modified Frailty Index is a reliable tool that can be used to identify high-risk patients for TCAR prior to intervention. This could help vascular surgeons, patients, and families in informed decision making to further optimize perioperative care and medical management in frail patients.