Frailty and functional decline after elective endovascular abdominal aortic aneurysm repair in octogenarians

Abstract

Objective: Frailty can be used to estimate perioperative and long-term mortality risk in octogenarians undergoing elective endovascular abdominal aortic aneurysm repair (EVAR). Its association with functional decline, an important surrogate of quality of life in older adults, has not been well-studied in this population. We aimed to evaluate whether preoperative factors such as frailty are associated with 1-year functional decline after elective EVAR in octogenarians and to compare the performance of three different frailty assessments. Methods: The Vascular Quality Initiative (VQI) database was queried for octogenarians who underwent elective EVAR for an asymptomatic infrarenal abdominal aortic aneurysm (2014- 2023). Functional status was measured using Eastern Cooperative Oncology Group performance status (0-1, independent; 2-4, impaired). Octogenarians who were functionally independent preoperatively and completed the 1-year follow-up were included. Frailty was assessed using the simple VQI-Frailty Score (sVQI-FS), VQI Risk Analysis Index (VQI-RAI), and Modified Frailty Index. The primary outcome was functional decline, defined as a change to impaired status at follow-up. Characteristics were compared between participants with and without decline. Stepwise regression in a development cohort derived models of risk factors for decline, repeated with each frailty assessment. Model performance was compared using a validation cohort. Results: Among 13,645 octogenarians, 75.6% (n = 10,327) were functionally independent preoperatively. The 1-year mortality rates was 9.1%, and 50.4% of survivors completed the 1-year follow-up within the allotted timeframe (n = 3561). Functional decline occurred in 18.3% (n = 490) of the development cohort (n = 2670), with 19.0% (n = 94) requiring assisted care and 0.2% (n = 1) becoming completely bedbound. Participants with functional decline were more likely to be older (84.7 years vs 83.7 years; P < .001), have more preoperative comorbidities including anemia (42% vs 34%), chronic obstructive pulmonary disease (31% vs 26%), and congestive heart failure (17% vs 13%), and score higher on the sVQI-FS (0.23 vs 0.21) and VQI Risk Analysis Index (32.4 vs 31.5) (P < .05 for each), but not the Modified Frailty Index (2.3 vs 2.2; P = .5). The sVQI-FS (odds ratio [OR], 3.02; 95% confidence interval [CI], 1.28-7.09), age (OR, 1.10 per year; 95% CI, 1.07-1.14), and restriction in physically strenuous activity (OR, 2.14; 95% CI, 1.75-2.62) were identified as independent risk factors for decline and, as a three-item model, achieved the greatest discrimination in the validation cohort. Conclusions: Functional decline affects 18% of octogenarians who survive to 1 year after elective EVAR. Older age, restricted activity, and frailty as measured by the sVQI-FS are strong risk factors and may help to identify octogenarians for prehabilitation.