Impact of Frailty and Sarcopenia on Thirty-Day and Long-Term Mortality in Patients Undergoing Elective Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis

Background: The aim of this study was to assess the prognostic role of frailty and sarcopenia on the survival of patients with AAA undergoing elective endovascular repair (EVAR). Methods: A systematic review of the literature was conducted in accordance with Meta-analysis of Observational Studies in Epidemiology (MOOSE). The association of frailty or sarcopenia with 30-day mortality and late survival was expressed as odds ratios (ORs) or hazard ratios (HRs) with a 95% confidence interval (CI). Meta-analysis random effects models were applied. The five-factor modified frailty index (mFI-5) was used as a frailty metric and sarcopenia was determined using computed tomography angiography (CTA) with measurements of the total psoas muscle area. Frailty was defined as patients with mFI-5 ≥ 0.6 and sarcopenia was defined as the total psoas muscle area (TPA) within the lowest tertile. Results: Thirteen observational cohorts reporting a total of 56,756 patient records were eligible for analysis. Patients with frailty (mFI-5 ≥ 0.6) had significantly increased 30-day mortality than those without frailty (random effects method: OR, 4.84, 95% CI 3.34-7.00, p < 0.001). Patients with sarcopenia (lowest TPA tertile) had significantly increased 30-day mortality according to the fixed effects method (OR, 3.30, 95% CI 2.17-5.02, p < 0.001), but not the random effects method (OR, 2.64, 95% CI 0.83-8.39, p = 0.098). Patients with sarcopenia or frailty had a significantly increased hazard ratio (HR) for late mortality than those without frailty or sarcopenia according to the random effects method (HR, 2.39, 95% CI 1.66-3.43, p < 0.001). The heterogeneity of the studies was low (I²: 0.00%, p = 0.86). The relation of frailty to age extracted from four studies demonstrates that the risk of frailty increases with age according to the random effects method (standard mean differences, SMD, 0.52, 95% CI 0.44-0.61, p < 0.001). The heterogeneity of the studies was low (I²: 0.00%, p = 0.64). Conclusions: Patients with sarcopenia or frailty have a significantly increased risk of mortality following elective EVAR. Prospective studies validating the use of frailty and sarcopenia for risk prediction after EVAR are needed before these tools can be used to support decision making.