Review of Frailty In Patients Undergoing Vascular Surgery

posted in: Varicose Veins

Frailty in patients is associated with the common view that frailty increases mortality rates in surgical procedures relating to the vascular system. Most of the available evidence from 52 peer-reviewed publications suggests that frailty most affects survival rates in the medium range of two years after surgery. [1]

However, other studies show less of a correlation between frail patients and postoperative death. A recent report published in vascular news recommended that surgeons, hospitals and medical practices stop using frailty as the sole factor in denying medical interventions. The evidence shows that other health conditions in elderly patients could easily be responsible for postoperative death. [2]

The article explained why these conclusions were made by John Houghton of the University of Leicester. The main conclusion of the report delivered by Houghton to a European Union’s scientific prize session was the recommendation to provide surgery and medical interventions if necessary when the only contraindication was patient frailty.

Review of Frailty In Patients Undergoing Vascular Surgery - Vein Solutions

Conclusions Based on Proceeding with Medical Interventions

There are ways to reduce any risks of frailty that include getting preoperative exercise, cognitive training and proper nutrition as well as controlling counterproductive behaviours that include smoking, alcohol use and others. Physicians should also ensure that the patient doesn’t have hypoalbuminemia, which is an extremely low concentration of albumin in the blood.

Frailty ranks as an independent risk factor in vascular surgery, and medical intervention shouldn’t be denied because of a single risk factor. The Houghton study investigated the methods commonly used to diagnose frailty and sarcopenia in vascular patients. Sarcopenia is a separate condition that causes muscle loss, and its effects are often diagnosed as patient frailty. [3]

Houghton contends that sarcopenia is often the underlying cause of increased deaths after vascular surgery instead of patient frailty. Comorbidities, according to Houghton, can also contribute to postoperative death rates. Comorbidities are defined as having two or more chronic health conditions. The current practice for diagnosing sarcopenia is to measure muscle mass and gauge functionality, but that leaves gaps when the problems of patients include obesity, unusual body-size adjustments and wide variety in the overall levels of fitness and pain.

Houghton recommended that physicians dig deeper into the patient’s lifestyle, demographics and medical histories before diagnosing patient frailty and using it as the sole factor in denying medical intervention. Frailty is defined as a state in which patients have difficulty recovering from stressors. Frail patients are subject to numerous poor outcomes that include poor recovery, loss of independence and death from minor stressors.

Sarcopenia, however, is a progressive loss of strength and function caused by reduced muscle mass and reduced quality of the skeletal muscles. The symptoms of both conditions are very similar – lack of energy, emotional distress and erosion of the abilities to handle daily routines.

What Is the Frailty Index for Elders?

Frailty in patients has shown distinct correlations between postoperative myocardial infarctions, strokes and extended hospital recovery times, but the evidence that frailty before vascular surgery causes increased death rates is controversial. The Frailty Index for Elders, abbreviated by the acronym FIFE, was developed using data from nurse databases. A 10-question survey asks about a patient’s physical capabilities, and a positive answer scores one point. A score of zero indicates no evidence of frailty, and a score of 1 to 3 indicates frailty risk. Scores of 4 or higher indicate frailty. [4]

The FIFE questions examine issues that include whether the patient needs help bathing and dressing or getting out of bed. The questions also explore whether the patient has lost weight, has physical health or emotional problems or gets tired easily. Many surgeons aren’t satisfied with FIFE as the sole means of determining frailty and insist on conducting further examinations and lab tests to determine frailty and its severity in their vascular patients.

Diagnosis of Frailty and Sarcopenia

The diagnosis of frailty and sarcopenia is often complicated by overlapping and similar symptoms, but clinical practitioners can definitely rule out sarcopenia with current diagnostic algorithms. The criteria for diagnosing the condition have been thoroughly examined, and the European Working Group on Sarcopenia in Older People established a clear diagnostic procedure. Physicians are directed to test for low muscle mass and functional weakening that includes a slower gait and low grip strength. [5] Weight loss, self-reported exhaustion and reduced physical activity also contribute to a diagnosis if patients have three or more of the five symptoms.

Conclusions of Studies that Favour Using Patient Frailty to Rule Out Surgery

Some researchers and physicians don’t agree with the conclusions of the Houghman report, and conducted a systematic review to test his theories. [6] The researchers reviewed 53 previous studies, but only seven of them were deemed to be both top-quality clinical studies and well-documented assessments of patient frailty.

The evidence of the effects of frailty on post surgical outcomes shows a high correlation to negative results, but there haven’t been many valid clinical evaluations of this topic. 18 of the studies provided data for meta analysis. The quality of the studies was evaluated using Newcastle–Ottawa scores, and the evidence was analysed using the Grading of Recommendations Assessment, Development and Evaluation approach, which goes by the acronym GRADE.

The researchers also independently tried to confirm patient frailty by studying the risk factors and changes in patient behaviour. Each case was expressed in terms of risk ratios, odds ratios and hazard ratios. All the data were pooled, and only data with a 95 percent confidence rate were used.

Study Results

The results of the systematic review of these 53 studies brought some surprising conclusions that disproved Houghton’s assertion that sarcopenia was misdiagnosed as patient frailty in many cases. The findings included the following insights:

  • Frailty was a condition brought on by ageing.
  • Females were more subject to frailty than males.
  • Frailty patients had higher 30-day mortality rates after medical interventions.
  • Frailty patients also experienced more postoperative complications.
  • Sarcopenia was not credited for any of these outcomes.

Is the Correlation Between Frailty and Postoperative Death Valid?

There remains concern about the criteria used to diagnose patient frailty. Physicians should make every effort to confirm the diagnosis independently instead of diagnosing frailty because they’ve eliminated sarcopenia or other maladies common to the elderly. There are easily 30 or more symptoms that define one condition or the other, but sarcopenia and frailty do share several symptoms.

Another respected study – based on elderly surgical patients for multiple conditions – reviewed relevant studies published in Embase, PubMed, Web of Science and the Cochrane Library databases [7] The study employed fixed-effects and random-effects models to combine risk ratios based on 95 percent confidence intervals. A subgroup analysis confirmed the results of the study.

The researchers confirmed 12 studies treating 2,278 patients as relevant and valid. The researchers concluded that patient frailty increased postoperative complications. The same held true for those identified as pre-frailty patients.

A recent study on the effect of frailty on cardiac surgery found similar results. The study was conducted on current patients at a cancer treatment center. Frailty was defined rather loosely as any physical impairment that precludes managing normal daily routines. [8] There were 3,826 patients in the study, and 4.1 percent, 157 people, were diagnosed with frailty. Most were women and older than the patient average.

The results were pretty conclusive. Frailty was an independent characteristic of in-hospital and at-home mortality. Patient frailty was also an independent predictor of mortality among midterm postoperative patients. Regardless of the type of medical intervention, careful frailty screening improves risk assessment and identifies patients who might benefit from new medical processes.

The question remains whether or not frailty contributes to death specifically after vascular surgery. The evidence seems to support increased mortality rates that can’t be explained by sarcopenia and other comorbidities. In these cases, the severity of the vascular problems must be taken into account by the physician and patient to determine if the odds favour intervention.


The confusion over the patient frailty issue leaves physicians and surgeons with a simple mandate – to use their best judgement on a case-by-case basis. Examining all the potential health issues and explaining the contradictory evidence to the patient can help the doctor and patient decide on a course of treatment for vascular problems.


[1] Frailty In Patients Undergoing Vascular Surgery: A Narrative Review Of Current Evidence–peer-reviewed-fulltext-article-TCRM

[2] No evidence to deny vascular intervention based on frailty score alone, despite association with poor outcomes

[3] On the Definition of Sarcopenia in the Presence of Aging and Obesity—Initial Results from UK Biobank

[4] The Frailty Index for Elders (FIFE)

[5] Sarcopenia and frailty: new challenges for clinical practice

[6] Frailty Factors and Outcomes in Vascular Surgery Patients

[7] Effects of the frailty phenotype on post-operative complications in older surgical patients: a systematic review and meta-analysis

[8] Frail Patients Are at Increased Risk for Mortality and Prolonged Institutional Care After Cardiac Surgery


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