Increased clinical frailty is associated with aortic-related mortality following fenestrated and branched endovascular repair for thoracoabdominal aortic aneurysm.

Abstract

Objective: Clinical frailty is associated with reduced long-term survival following fenestrated and branched endovascular aortic repair (F/BEVAR). This study assesses the impact of phenotypic clinical frailty on perioperative outcomes and cause of death following F/BEVAR for thoracoabdominal aortic aneurysm.

Methods: Patients who underwent F/BEVAR at a single institution from 2012 to 2024 were identified. The clinical frailty scale (CFS) was used to determine phenotypic frailty. Patients with preoperative CFS>4 ("vulnerable") and CFS<4 were compared. Chi-squared and Fischer Exact tests were used to compare patient demographics, anatomic and operative characteristics, and perioperative outcomes. Fine-Gray analysis was used to compare cause of death between groups. Long-term survival and reintervention were assessed with Kaplan-Meier and Cox regression analysis.

Results: 233 patients were included; 60 (25.8%) had CFS>4 and 173 (74.2%) had CFS<4. Patients with CFS>4 were more likely to have COPD (53% vs. 27%) and were treated for slightly larger aneurysms (72 mm vs 68 mm, p=0.04). There were no differences in symptomatic presentation, aneurysm extent, or operative complexity between patient groups. Additionally, there were no differences in perioperative complications including 30-day mortality, stroke, and spinal cord ischemia. Patients with CFS>4 had an increased length of hospitalization (11.3 vs 6.9 days, p<0.01) and were less likely to return to preoperative functional status (62.7% vs 86.1%, p<0.01). Three-year all-cause and aortic-related mortality rates were 35.2% and 5.7%, respectively. Patients with CFS>4 had reduced survival at 1-year (74% vs 89%), 3-years (39% vs 73%), and 5-years (25% vs 56%), compared to patients with CFS<4 (p<0.01). The most common causes of death among both groups were pulmonary comorbidities (14.0%), oncologic conditions (14.0%), cardiovascular comorbidities (11.2%), and procedure-related complications (11.2%). Patients with CFS>4 were more likely to die from aortic-related mortality (10.3% vs 5.9%, p=0.02), pulmonary comorbidities (15.4 vs 13.2%, p=0.04), systemic decline (7.7% vs 1.5%, p=0.02), and infection (12.8% vs 7.4%, p=0.03). Aortic-related mortality for the entire patient cohort was 2.2% and 5.7% at 1-year and 3-years, respectively. Aortic-related deaths among clinically frail patients were often due to an inability to tolerate further aortic operations (e.g. arch repair), and secondary to follow-up non-adherence in patients with with CFS<4.

Conclusion: In an expanded cohort of patients, clinical frailty was associated with reduced long-term survival and increased risk for aortic-related mortality following F/BEVAR for treatment of thoracoabdominal aortic aneurysms. Chronic disease burden is a primary driver of overall mortality, while clinically frail patients are more likely to die from pulmonary comorbidities, infection, and systemic decline. Phenotypic frailty assessment should be considered in preoperative assessment and patient counseling prior to F/BEVAR.