A Frailty-Based Risk Score Predicts Morbidity and Mortality After Elective Endovascular Thoracic Aortic Aneurysm Repair

Thoracic endovascular aortic repair (TEVAR) has expanded access to thoracic aortic aneurysm (TAA) repair, particularly for elderly and frail patients. However, there are limited data on this higher risk population to inform appropriate selection of patients. Our objective was to develop and to validate a frailty-based, procedure-specific risk score for patients undergoing TEVAR for elective TAA. Patients undergoing nonemergent TEVAR for TAA during 2005 to 2016 in the National Surgical Quality Improvement Program database were randomized to derivation or validation cohorts. The primary outcome was 30-day major adverse events (MAEs), including mortality and major complications. Using the derivation cohort, variables associated with MAEs were identified by univariable analyses. Those with P < .05 were included in multivariable logistic regression analysis. Independent procedure-specific and frailty-related risk factors for MAEs were used to develop a pragmatic score to assess risk for TEVAR. Overall, 1920 patients were included (960 derivation, 960 validation); 16% of derivation patients had MAEs (15% major complications, 4% mortality), which were primarily associated with markers of frailty and TEVAR extent (Table). Independent risk factors for MAEs were chronic pulmonary disease (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.3-2.6), functional dependence (OR, 2.9; 95% CI, 1.7-5.2), and zone 2 involvement (OR, 1.7; 95% CI, 1.2-2.4). Assigning each variable 1 point, a total risk score of 0 to 3 was generated with progressive rates of MAEs (Fig), enabling classification as low risk (0 points; 38% of patients; mortality <5%; MAEs <15%), intermediate risk (1 point; 45% of patients; mortality <10%; MAEs <20%), or high risk (≥2 points; 17% of patients; mortality >10%; MAEs >20%). Validation patients had similar characteristics and calculated risk profile. Markers of frailty and procedure extent strongly predict MAEs after TEVAR for TAA and can improve selection of patients by enabling patient- and procedure-specific risk stratification. Whereas TEVAR is safe in low-risk patients, intermediate-risk patients warrant careful discussion of the risks and benefits of aortic intervention; under certain circumstances, high-risk patients may not benefit. Further study is required to define the association between frailty and long-term outcomes.TableRisk factors for major adverse events (MAEs)Derivation, no MAEs (n = 803)Derivation, MAEs (n = 157)PAge, years, median (IQR)72 (64-78)73 (66-77).18Female358 (45)71 (45).88Dependent functional status38 (5)22 (14)