The association of abdominal muscle with outcomes after scheduled abdominal aortic aneurysm repair

Psoas muscle analysis as a surrogate marker of sarcopenia and frailty: A multicenter analysis of predictive capacities over short- and long-term outcomes after abdominal aortic aneurysm repair

OBJECTIVES

Several predictive models exist for estimating the postoperative risks of abdominal aortic aneurysm (AAA) repair, although no particular tool has seen widespread use. We present the results of a multicenter, historic cohort study comparing the predictive capacity of the psoas muscle area (PMA), radiodensity (PMD), and lean muscle area (LMA) as surrogate markers of sarcopenia, over short- and long-term outcomes after AAA repair, compared to the mFI-5 and American Society of Anesthesiologists (ASA) scales.

METHODS

Retrospective review was conducted of all consecutive AAA elective repair cases (open or endovascular) in three tertiary-care centers from 2014 to 2019. Cross-sectional PMA, PMD, and LMA at the mid-body of the L3 vertebra were measured by two independent operators in the preoperative computed tomography. Receiver operating characteristic (ROC) curves were used to determine optimal cutoff values. Bivariate analysis, logistic regression, and Cox's proportional hazards models were built to examine the relationship between baseline variables and postoperative mortality, long-term mortality, and complications.

RESULTS

596 patients were included (mean age 72.7 ± 8 years, 95.1% male, 66.9% EVAR). Perioperative mortality was 2.3% (EVAR 1.2% vs open repair 4.6%, p = .015), and no independent predictors could be identified in the multivariate analysis. Conversely, an age over 74 years old (OR 1.84 95%CI 1.25-2.70), previous heart diseases (OR 1.62 95%CI 1.13-2.32), diabetes mellitus (OR 1.61 95%CI 1.13-2.32), and a PMD value over 66 HU (OR 0.58 95%CI 0.39-0.84) acted as independent predictors of long-term mortality in the Cox's proportional hazards model. Heart diseases (congestive heart failure or coronary artery disease), serum creatinine levels over 1.05 mg/dL, and an aneurysm diameter over 60 mm were independent predictors of major complications.

CONCLUSION

Surrogate markers of sarcopenia had a poor predictive profile for postoperative mortality after AAA repair in our sample. However, PMD stood out as an independent predictor of long-term mortality. This finding can guide future research and should be confirmed in larger datasets.

Comparison Between Several CT-Derived Psoas Muscle Sarcopenia Markers for Predicting Survival After Abdominal Aortic Aneurysm Repair

BACKGROUND

Multiple CT-derived measurements of sarcopenia have been described yet their relationship with survival after abdominal aortic aneurysm (AAA) repair has not been properly assessed. We aimed to define and compare the relationship between several psoas CT-derived measurements and the 5-year survival after AAA repair and to evaluate their potential contribution to survival prediction.

METHODS

Preoperative CT area (TPA) and density (MTPD) of the psoas muscle at L3 were measured in 218 consecutive AAA patients electively intervened. Additional measurements were obtained by normalizing TPA by anthropometric data or L3-vertebra surface or by TPAxMTPD multiplication (lean psoas muscle area-LPMA). The association of sarcopenia markers with survival was evaluated with Cox models adjusted by age, sex, type of intervention and the Charlson Comorbidity Index, and their contribution to survival prediction assessed with the C-statistic and the Continuous Net Reclassification Index (c-NRI).

RESULTS

Sixty patients (27.5%) died during the first 5 years after surgery. There was a statistically significant and linear (spline analysis) relationship of sarcopenia markers with 5-year survival in all multivariate models, except that including LPMA. Despite this association, the inclusion of sarcopenia markers did not improve the C-statistic and moderately increased the c-NRI. None normalized sarcopenia markers performed better than TPA.

CONCLUSION

The majority of CT-derived psoas muscle measurements of sarcopenia showed a significant and independent relationship with survival after elective AAA repair. Despite this association, they did not appear to improve sufficiently our survival prediction ability to become an efficient tool for decision-making.

Current Clinical Implications of Frailty and Sarcopenia in Vascular Surgery: A Comprehensive Review of the Literature and Consideration of Perioperative Management

Frailty is a well-known geriatric syndrome of impaired physiological reserve and increased vulnerability to stressors. Sarcopenia is also used as a parameter of physical impairment characterized by muscle weakness. As population aging has become more prominent in recent years, both modalities are now regarded as clinically important prognostic tools defined by multidimensional factors that may affect clinical outcomes in various clinical settings. A preoperative surgical risk analysis is mandatory to predict clinical and surgical outcomes in all surgical practices, particularly in high-risk surgical patients. In vascular surgical settings, frailty and sarcopenia have been accepted as useful prognostic tools to evaluate patient characteristics before surgery, as these may predict perioperative clinical and surgical outcomes. Although minimally invasive surgical approaches, such as endovascular therapy, and hybrid approaches have been universally developed, achieving good vascular surgical outcomes for high-risk cohorts remains to be challenge due to the increasing prevalence of elderly patients and multiple preoperative co-morbidities in addition to frailty and sarcopenia. Therefore, to further improve clinical and surgical outcomes, these preoperative geriatric prognostic factors will be of great importance and interest in vascular surgical settings for both physicians and surgeons.

Comparison of ultrasound speed-of-sound of the lower extremity and lumbar muscle assessed with computed tomography for muscle loss assessment

To compare the speed of propagation of ultrasound (US) waves (SoS) of the lower leg with the clinical reference standard computed tomography (CT) at the level of lumbar vertebra 3 (L3) for muscle loss assessment. Both calf muscles of 50 patients scheduled for an abdominal CT were prospectively examined with ultrasound. A plexiglas-reflector located on the opposite side of the probe with the calf in between was used as a timing reference for SoS (m/s). CT measurements were performed at the level of L3 and included area (cm2) and attenuation (HU) of the psoas muscle, abdominal muscles, subcutaneous fat, visceral fat and abdominal area. Correlations between SoS, body mass index (BMI) and CT were determined using Pearson's correlation coefficient. Based on reported CT sarcopenia threshold values, receiver operating characteristic (ROC) analysis was performed for SoS. Inter-examiner agreement was assessed with the median difference, inter-quartile range (IQR) and intraclass correlation coefficients. SoS of the calf correlated moderately with abdominal muscle attenuation (r = 0.48; P < .001), psoas muscle attenuation (r = 0.40; P < .01), abdominal area (r = -0.44; P < .01) and weakly with subcutaneous fat area (r = -0.37; P < .01). BMI correlated weakly with psoas attenuation (r = -0.28; P < .05) and non-significantly with abdominal muscle attenuation. Normalization with abdominal area resulted in moderate correlations with abdominal muscle area for SoS (r = 0.43; P < .01) and BMI (r = -0.46; P < .001). Based on sarcopenia threshold values for skeletal muscle attenuation (SMRA), area under curve (AUC) for SoS was 0.724. Median difference between both examiners was -3.4 m/s with IQR = 15.1 m/s and intraclass correlation coefficient = 0.794. SoS measurements of the calf are moderately accurate based on CT sarcopenia threshold values, thus showing potential for muscle loss quantification.

Sarcopenia and Adverse Post-Surgical Outcomes in Geriatric Patients: A Scoping Review

BACKGROUND

Sarcopenia is associated with adverse outcomes in cancer, chemotherapy, solid organ transplants, intensive care and medical patients. It has also been proven to increase perioperative mortality, hospital length of stay and complications in patients of various age groups. However, a limited number of studies have examined the association of post-surgical outcomes and sarcopenia inclusively in patients aged 65 years and older.

OBJECTIVE

This scoping review aimed to examine the relationship between adverse post-surgical outcomes and sarcopenia in patients aged 65 years and older.

METHODOLOGY

EMBASE and Medline databases were searched for sarcopenia, perioperative period and post-surgical outcomes. The articles were screened based on exclusion and inclusion criteria and were reviewed systematically as per the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews.

RESULTS

After duplicates removal and application of the inclusion and exclusion criteria, eight articles were included for this study from a total of nine hundred initially identified articles. All studies defined sarcopenia as low muscle mass but did not include physical function or muscle strength as the parameter of sarcopenia. Low muscle mass was associated with higher mortality in emergency surgeries, reduced long term survival in open elective surgeries, and increased length of hospital stay in endoscopic surgeries.

CONCLUSION

The current review suggests that low muscle mass is associated with higher mortality and various adverse post-surgical outcomes in the elderly. It remains to be determined if applying the definition of sarcopenia as per the international consensus/guidelines will affect the association of adverse post-surgical outcomes and sarcopenia.

Psoas muscle area and attenuation are highly predictive of complications and mortality after complex endovascular aortic repair

OBJECTIVE

The present study evaluated the psoas muscle area and attenuation (radiodensity), quantified by computed tomography, together with clinical risk assessment, as predictors of outcomes after fenestrated and branched endovascular aortic repair (FBEVAR).

METHODS

The present single-center study included 504 patients who had undergone elective FBEVAR for pararenal or thoracoabdominal aortic aneurysms. The clinical risk assessment included age, sex, comorbidities, body mass index, glomerular filtration rate, aneurysm size and extent, cardiac stress test results, ejection fraction, and American Society of Anesthesiologists (ASA) score. Preoperative computed tomography was used to measure the psoas muscle area and attenuation at the L3 level. The lean psoas muscle area (LPMA; area in cm² multiplied by attenuation in Hounsfield units [HU]) was calculated by multiplying the area by the attenuation. The risk factors for 90-day mortality, major adverse events (MAEs), and long-term mortality were determined using multivariable analysis. MAEs included 30-day or in-hospital death, acute kidney injury, myocardial infarction, respiratory failure, paraplegia, stroke, and bowel ischemia. A novel risk stratification method was proposed according to the strongest predictors of mortality and MAEs on multivariable analysis.

RESULTS

The 30-day mortality, 90-day mortality, and MAE rates were 2.0%, 5.6%, and 20%, respectively. The independent predictors of 90-day mortality were chronic obstructive pulmonary disease, chronic kidney disease, ASA score, and LPMA. The independent predictors of MAEs were aneurysm diameter, glomerular filtration rate, and LPMA. For long-term mortality, the independent predictors were chronic kidney disease, congestive heart failure, extent I-III thoracoabdominal aortic aneurysms, ASA score, and LPMA. The patients were stratified into three groups according to the ASA score and LPMA: low risk, ASA score II or LPMA >350 cm²HU (n = 290); medium risk, ASA score III and LPMA ≤350 cm²HU (n = 181); and high risk, ASA score IV and LPMA ≤350 cm²HU (n = 33). The 90-day mortality and MAE rates were 1.7% and 16% in the low-, 7.2% and 24% in the medium-, and 30% and 33% in the high-risk patients, respectively (P < .001 and P = .02, respectively). Patients with ASA score IV and LPMA <200 cm²HU, indicating sarcopenia (n = 14) had a 43% risk of death within 90 days. The 3-year survival estimates were 80% ± 3% for the low-, 70% ± 4% for the medium-, and 35% ± 9% for the high-risk patients (P < .001). The mean follow-up time was 3.1 ± 2.3 years.

CONCLUSIONS

LPMA was a strong predictor of outcomes and the only independent predictor of both mortality and MAEs after FBEVAR. A high muscle mass was protective against complications, regardless of the ASA score. Risk stratification based on the ASA score and LPMA can be used to identify patients at excessively high operative risk.

Frailty Factors and Outcomes in Vascular Surgery Patients: A Systematic Review and Meta-analysis

OBJECTIVE

To describe and critique tools used to assess frailty in vascular surgery patients, and investigate its associations with patient factors and outcomes.

BACKGROUND

Increasing evidence shows negative impacts of frailty on outcomes in surgical patients, but little investigation of its associations with patient factors has been undertaken.

METHODS

Systematic review and meta-analysis of studies reporting frailty in vascular surgery patients (PROSPERO registration: CRD42018116253) searching Medline, Embase, CINAHL, PsycINFO, and Scopus. Quality of studies was assessed using Newcastle-Ottawa scores (NOS) and quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria. Associations of frailty with patient factors were investigated by difference in means (MD) or expressed as risk ratios (RRs), and associations with outcomes expressed as odds ratios (ORs) or hazard ratios (HRs). Data were pooled using random-effects models.

RESULTS

Fifty-three studies were included in the review and only 8 (15%) were both good quality (NOS ≥ 7) and used a well-validated frailty measure. Eighteen studies (62,976 patients) provided data for the meta-analysis. Frailty was associated with increased age [MD 4.05 years; 95% confidence interval (CI) 3.35, 4.75], female sex (RR 1.32; 95% CI 1.14, 1.54), and lower body mass index (MD -1.81; 95% CI -2.94, -0.68). Frailty was associated with 30-day mortality [adjusted OR (AOR) 2.77; 95% CI 2.01-3.81), postoperative complications (AOR 2.16; 95% CI 1.55, 3.02), and long-term mortality (HR 1.85; 95% CI 1.31, 2.62). Sarcopenia was not associated with any outcomes.

CONCLUSION

Frailty, but not sarcopenia, is associated with worse outcomes in vascular surgery patients. Well-validated frailty assessment tools should be preferred clinically, and in future research.

CT-Derived Pretreatment Thoracic Sarcopenia Is Associated with Late Mortality after Thoracic Endovascular Aortic Repair

BACKGROUND

Frailty, characterized by physiologic depletion, predicts postoperative morbidity and mortality in vascular surgery patients. CT-derived sarcopenia is a valuable method for objectively staging frailty preoperatively.

PURPOSE

With prior analyses primarily measuring psoas cross-sectional area on CT, we compared a method of measuring thoracic sarcopenia to existing techniques of lumbar sarcopenia and assessed the association with long-term survival and outcomes post-Thoracic Endovascular Aortic Repair (TEVAR).

METHODS

Prospectively collected data of 217 patients undergoing TEVAR from 2009 to 2012 were reviewed. Thoracic sarcopenia was quantified by measuring total area of the rectus abdominis, latissimus dorsi, intercostal, erector spinae, and external and internal oblique muscles at the T12 vertebral level. Total psoas area at the L3 was used to measure lumbar sarcopenia.

RESULTS

200 patients had preoperative imaging enabling measurements of thoracic sarcopenia, 186 of these patients were also assessed for lumbar sarcopenia. Thoracic sarcopenic patients were older, had lower body mass indices, were more commonly female, and most commonly being treated for aneurysms. Thoracic sarcopenic patients had significantly higher rates of congestive heart failure, hypertension, prior vascular intervention, and TEVAR-related adverse events. Thoracic sarcopenia was associated with significantly higher mortality at 2 and 5 years post-TEVAR (2-year mortality: 19% vs 8%, P = 0.02; 5-year mortality: 31% vs 18%, P = 0.03). Lumbar sarcopenia was not associated with increased mortality at any time point. Patients whose muscle mass degraded over 48-month follow-up did not experience significantly higher rates of adverse events.

CONCLUSIONS

CT-derived thoracic sarcopenia, but not lumbar sarcopenia, is significantly associated with 5-year mortality post-TEVAR.

The Relation between Sarcopenia and Mortality in Patients at Intensive Care Unit

Background and Aim

Psoas muscle area (PMA) can reflect the status of skeletal muscle in the whole body. It has been also reported that decreased PMA was associated with postoperative mortality or morbidity after several surgical procedures. In this study, we aimed to investigate the relation between PMA and mortality in all age groups in intensive care unit (UNIT).

Materials and Method

The study consists of 362 consecutive patients. The demographic characteristics of patients, indications for ICU hospitalization, laboratory parameters, and clinical parameters consist of mortality and length of stay, and surgery history was obtained from intensive care archive records.

Results

The mean age was 61.2 ± 18.2 years, and the percentage of female was 33.3%. The mean duration of stay was 10.3 ± 24.4 days. Exitus ratio, partial healing, and healing were 25%, 70%, and 5%, respectively. The mean right, left, and total PMA were 8.7 ± 3.6, 8.9 ± 3.4, and 17.6 ± 6.9, respectively. The left and total PMA averages of the nonoperation patients were statistically significantly lower (p = 0.021  p = 0.043). The mean PMA between the ex and recovered patients were statistically significantly lower (p = 0.001, p = 0.001, p < 0.001). Dyspnoea, renal insufficiency, COPD, transfusion rate, operation rate, ventilator needy, and mean duration of hospitalization were statistically significant higher in patients with exitus. There is a significant difference in operation types, anesthesia type, and clinic rates.

Conclusion

Our data suggest that sarcopenia can be used to risk stratification in ICU patients. Future studies may use this technique to individualize postoperative interventions that may reduce the risk for an adverse discharge disposition related to critical illness, such as early mobilization, optimized nutritional support, and reduction of sedation and opioid dose.