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. Author manuscript; available in PMC: 2023 Nov 1.
Published in final edited form as: J Vasc Surg. 2022 Jun 3;76(5):1407–1416. doi: 10.1016/j.jvs.2022.05.005

Scoping review of radiological assessment and prognostic impact of skeletal muscle sarcopenia in patients undergoing endovascular repair for aortic disease

Luca Mezzetto 1,*, Mario D’Oria 2,*, Kevin Mani 3, Salvatore Scali 4, Frederico Baston Goncalves 5, Santi Trimarchi 6, Jacob Budtz-Lilly 7, Randall DeMartino 8, Gianfranco Veraldi 1, Davide Mastrorilli 1, Cristiano Calvagna 2, Beatrice Grando 2, Daniele Bissacco 6, Sandro Lepidi 2
PMCID: PMC9613481  NIHMSID: NIHMS1814767  PMID: 35667604

Abstract

Objective.

The primary objectives of this scoping review were to evaluate the methods used by research groups to assess the incidence of sarcopenia in patients with aortic disease, to assess the extent of the evidence base that links sarcopenia to survival of patients undergoing elective endovascular aortic repair, and to identify recurring themes or gaps in the literature to guide future research.

Methods.

A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available studies fully published in English (last queried, 31 December 2021) were sought. The following PICO question was used to build the search equation: in patients with aortic disease (Population) undergoing endovascular repair (Intervention), what is the prevalence and prognosis of radiologically defined sarcopenia (Comparison) on short- and long-term outcomes?

Results.

31 articles were considered as relevant and 18 were included in the scoping review. Briefly, 12 papers focused on standard endovascular aneurysm repair (EVAR), 2 on thoracic EVAR (TEVAR), and 4 on complex EVAR (CoEVAR). All but two studies were retrospective in design and only one manuscript included patients from a multicenter database. Sarcopenia was generally defined by using the computed tomography angiography (CTA) with cross-sectional area of psoas muscle (PMA) at L3 or L4, sometimes with normalization against the height. Overall, despite the heterogeneity in the methods employed for its definition, sarcopenia was highly prevalent (ranged between 12.5%-67.6%). Sarcopenic patients had higher rates of mortality (ratios ranging between 2.28 (95%CI 1.35-3.84)) and adverse events (6.34 (95%CI 3.37-10.0).

Conclusions.

Sarcopenia, as identified using CTA-based measurements of skeletal muscle mass, is prevalent among patients undergoing elective EVAR, TEVAR or CoEVAR. Presence of sarcopenia has been shown to have a negative prognostic impact increasing operative risk and is linked to poorer long-term survival.

Keywords: Aortic disease, Aortic aneurysm, Endovascular repair, Sarcopenia, Scoping review, Outcomes

Table of Contents Summary

Sarcopenia, as identified using CTA-based measurements of skeletal muscle mass, can be frequently found in patients undergoing elective EVAR, TEVAR or F-BEVAR. Presence of sarcopenia has been shown to have a negative prognostic impact and linked to poorer long-term survival. Therefore, its assessment might become a useful adjunctive tool that could complement the risk-stratification process of patients who are candidates for elective endovascular repair of aortic diseases. Future studies should investigate the optimal methodology and thresholds that should be used in clinical practice, with the hope to provide a fuller understanding of how the recognition and management of sarcopenia may improve clinical outcomes and resource utilization.

Introduction

Over the last two decades, endovascular techniques for repair of disease in the abdominal, thoracoabdominal and thoracic aorta have increasingly become the first-line treatment option for patients with suitable anatomy, mainly due to their reduced invasiveness compared to classical open surgical repair. This has contributed to a significant shift in management as more patients have become eligible for intervention, even if their age and comorbidities would have otherwise rendered them unsuitable for open repair .1

As the ultimate goal of prophylactic exclusion of aortic aneurysms remains the prevention of rupture and subsequent aortic-related death, there is a subset of older or frail patients who will die from non-aneurysm-related causes during short-term follow-up, thereby rendering some prophylactic endovascular aortic interventions non-beneficial. Therefore, careful patient selection remains a crucial component of the preoperative assessment for surgeons. Indeed, accurate identification of patients at increased risk for early or late mortality may help inform the decisions for patients, caregivers, and providers regarding potential benefits of elective aortic surgery.2

Sarcopenia has been defined as progressive skeletal muscle loss and systemic dysfunction associated with aging, but also recognized to be a prognostic factor for survival, complications, and quality of life for various pathologies 3. Loss of subcutaneous fat and muscle hypotrophy, associated with adipocyte and lipid accumulation in skeletal muscle (defined as “myosteatosis”) can be identified using computed tomographic angiography (CTA) and distinguish between sarcopenic and non-sarcopenic patients. Sarcopenia has been shown to bear potential as a risk-stratification tool and may therefore facilitate the surgical decision-making progress. Assessment of sarcopenia based on psoas muscle quality may be achieved in endovascular aortic repair candidates using pre-operative CTA, which is routinely available before any elective intervention as it is used for planning and sizing of the stent-grafts 4. In that sense, evaluation of sarcopenia in this subset of patients could be cost-effective, as the dataset needed for its assessment would already be available as part of their routine preoperative workup.

The primary objectives of this scoping review were to assess the methods used by research groups to characterize the incidence of sarcopenia in patients with aortic disease, determine the extent of the evidence base that links sarcopenia to survival of patients undergoing elective endovascular aortic repair, and identify recurring themes or gaps in the literature to guide future research 5.

Methods

Study design

A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed 6 (Figure 1). Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 April 2022) were systematically reviewed and analyzed. Reference lists from all included manuscripts were also manually screened and included, if necessary. The following PICO question was used to build the search equation: in patients with aortic disease (Population) undergoing elective endovascular repair (Intervention), what is the prevalence and prognosis of radiologically defined sarcopenia (Comparison) on short- and long-term outcomes (Outcomes)?

Figure 1.

Figure 1.

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PRISMA flowchart of literature selection.

For the purpose of this study, sarcopenia was defined by progressive loss of muscle mass and function, as measured on CTA using muscle cross-sectional area at either the lumbar or thoracic level 7–8.

Only full-text articles focusing on clinical effects of sarcopenia in patients undergoing endovascular abdominal aortic repair (EVAR), endovascular thoracic aortic repair (TEVAR), or complex EVAR (CoEVAR), including fenestrated/branched endograft (F/BEVAR) and chimney or parallel grafts, were included in our study. Any type of diagnosis and indications for treatment, when reported by Authors, were included in the analysis. Specific search terms and keywords were: (‘EVAR’ OR ‘FEVAR’ OR ‘BEVAR’ OR ‘TEVAR’ OR ‘aortic aneurysm repair’ OR ‘chimney’ OR ‘parallel graft’) AND (‘sarcopenia’ OR ‘muscle area’ OR ‘muscle volume’ OR ‘frailty’). Identified titles and abstracts were reviewed by two independent authors (L.M, M.D) and any areas of disagreement were discussed with a third author (D.M.). Manuscripts without the description of the protocol for muscle measurement were excluded. Duplicate copies of articles were identified and removed. Manuscripts were also excluded if they were case-reports, letters, editorials, commentaries or were written in a language other than English.

Data extraction

The following variables were abstracted: year and country of study, study design, patient number, demographics, sarcopenia measurements, intervention type, as well as short- and long-term outcomes (with mean follow-up time) between sarcopenic vs. non-sarcopenic patients. Any other notable finding identified in sarcopenic patients was also registered. Data were reported as descriptive narrative or tables, without any statistical analysis nor quality assessment of the included papers, in accordance with the PRISMA guidelines for scoping reviews 6.

Results

Literature search

After reviewing full texts, 31 articles were considered as relevant and 18 were finally included in the scoping review (Figure 1). The remaining manuscripts were excluded because they did not clearly report the measurement of sarcopenia or the outcome of sarcopenic patients after treatment. Briefly, 12 papers focused on EVAR, 2 on TEVAR, and 4 on CoEVAR, in which included elective and non-elective presentations. All but two studies were retrospective in design and only one included patients from a multicenter database. There were no randomized controlled trials available for inclusion (Table I). Abdominal aortic aneurysm was the unique diagnosis in the patients who underwent standard EVAR, while degenerative aneurysm, aortic dissection and trauma were also included in manuscripts reporting TEVAR and CoEVAR.

Table I.

Characteristics of studies included in the final analysis. (EVAR: endovascular aortic repair; TEVAR: thoracic endovascular aortic repair; AdEVAR: advanced endovascular aortic repair; AAA: abdominal aortic aneurysm; DTAA: descending thoracic aortic aneurysm; TAD: thoracic aortic dissection).

Authors Year Country Type of study Period of enrollment  Type & Number of procedures Indications for procedures
Hale et al. 9 2016 USA Retrospective Single-centre 1999-2007 EVAR, 200 AAA
Newton et al. 10 2018 USA Retrospective Single-centre 2010-2016 EVAR, 135 AAA
Thurston et al. 4 2018 Australia Retrospective Multi-centre 2008-2013 EVAR, 191 AAA
Tanaka et al. 11 2018 USA Retrospective Single-centre 2007-2015 TEVAR, 71 DTAA
Cheng et al. 12 2019 USA Retrospective Single-centre 2002-2014 EVAR, 272 AAA
Huber et al. 13 2019 USA Retrospective Single-centre 2010-2017 EVAR, 407 AAA
Waduud et al. 14 2019 UK Retrospective Single-centre 2008-2016 EVAR, 253 AAA
Olson et al. 15 2019 USA Retrospective Single-centre 2009-2012 TEVAR, 186 DTAA, TAD, Aortic trauma
Ito et al. 16 2020 Japan Retrospective Single-centre 2011-2018 EVAR, 310 AAA
Lindström et al. 17 2020 Finland Retrospective Single-centre 2006-2016 EVAR, 122 AAA
Oliveira et al. 18 2020 Portugal Retrospective Single-centre 2014-2018 EVAR, 105 AAA
Kärkkäinen et al. 19 2020 USA Prospective Single-centre 2013-2018 AdEVAR, 244 AAA TAAA
Ouchi et al. 20 2020 Japan Retrospective Single-centre 2015-2018 EVAR AdEVAR, 201 AAA
Ikeda et al. 21 2021 Japan Retrospective Single-centre 2007-2013 EVAR, 324 AAA
Lindström et al. 22 2021 Finland Retrospective Single-centre 2001-2014 EVAR, 216 AAA
Kärkkäinen et al. 23 2021 USA Retrospective Single-centre 2007-2019 AdEVAR, NA AAA TAAA
Alenezi et al. 24 2021 Canada Retrospective Single-centre 2008-2019 AdEVAR, 257 TAAA TAD
Paajanen et al.25 2022 Finland Retrospective Multi-centre 2006-2016 EVAR, 480 AAA
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Definition of sarcopenia and Characteristics of patients

Our analysis of radiologically-defined sarcopenia revealed several issues related to notable differences in baseline patients characteristics (including age, sex, race, BMI and cardiovascular risk factors), as well as a high degree of heterogeneity that contributed to variation in the radiological evaluation of sarcopenia 19,23. Prevalence of sarcopenia was not always reported and it ranged between 12.5% to 67.6%, according to different characteristics of the included cohorts and different modalities of sarcopenia measurement (Table II).

Table II.

Radiological methods for measurement of psoas muscle mass at computed tomography angiography (CTA) and cut-off for definition of sarcopenia in patients undergoing elective endovascular aortic repair.

Authors Method of measurement at CTA Thresholds of sarcopenia Prevalence of sarcopenia
Hale et al.9 Total Muscle Area at L3 (muscle areas of abdominal wall, paraspinal and psoas) <114cm2 (male)
<89.8cm2 (female)		 12.5%
Newton et al. 10 Psoas Muscle Area at L4 <24cm2 33.3%
Thurston et al. 4 Psoas Muscle Area at L3 <5cm2/m2 15.7%
Tanaka et al. 11 Normalized Psoas Muscle Area at L3 <6.5cm2/m2 NA
Cheng et al. 12 Normalized Psoas Muscle Area at L3 <5cm2/m2 18.3
Huber et al. 13 Psoas Muscle Area at L4 <14cm2 NA
Waduud et al. 14 Psoas Muscle Area at L3
Normalized Psoas Muscle Area at L3		 NA
NA		 NA
Olson et al. 15 Normalized Psoas Muscle Area at T12 and L3 THORACIC: <110cm2/m2 (male), <106cm2/m2 (female)
LUMBAR: <52.4cm2/m2 (male); <38.5cm2/m2 (female)		 NA
Ito et al. 16 Normalized Psoas Muscle Area at L3 <48.2cm2/m2 (male)
<37.4cm2/m2 (female)		 NA
Lindström et al. 17 Psoas Muscle Area at L3
Lean Psoas Muscle Area at L3		 NA
NA		 NA
Oliveira et al. 18 Psoas Muscle Area at L3
Lean Psoas Muscle Area at L3		 <12.07cm2
<607.7cm2xHU		 NA
Kärkkäinen et al. 19 Lean Psoas Muscle Area at L3 <350cm2HU 67.6%
Ouchi et al. 20 Psoas Muscle Area at L3 NA NA
Ikeda et al. 21 Psoas Muscle Area at L4 <16.1cm2 51.2%
Lindström et al. 22 Psoas Muscle Area at L3
Lean Psoas Muscle Area at L3		 NA NA
Kärkkäinen et al. 23 Lean Psoas Muscle Area at L3 <200cm2HU NA
Alenezi et al. 24 Psoas Muscle Area at L3 <17.4cm2 (male), <10.6cm2 (female) 33.4%
Paajanen et al.25 Psoas Muscle Area at L3 <8.0cm2 (male)
<5.5cm2 (female)		 58.5%
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These demographic differences emerged in several manuscripts included in this analysis. In their study, Cheng et al. 12 reported older age (75.5y vs. 70.0y, p=0.002), higher female prevalence (24% vs. 10%, p=0.02), lower body-mass-index (BMI) (25.7kg/m2 vs. 29.1 kg/m2, p=0.001), higher incidence of cancer (40% vs. 23%, p=0.02) and stroke (18% vs. 5%, p=0.003) in sarcopenic vs. non-sarcopenic patients. Similarly, sarcopenic patients were older (77.9y vs. 73y), and more likely to be female (32% vs. 9.7% p=0.005) and have lower BMI (24kg/m2 vs. 29kg/m2, p=0.001) in other experiences.4,9,10 No other significant associations between sarcopenia and patient characteristics were identified after careful review of the available literature. 9

Radiological evaluation of sarcopenia has not been well standardized throughout the literature, and different techniques have been employed (Table II). According to most of the included studies, axial CTA images with a slice thickness of 2mm or less, obtained between 90 days before or 30 days after the index procedure (i.e. peri-operatively), were used for muscle evaluation and data were transferred to a standard post-processing workstation, such as Carestream (Carestream Health Inc, Rochester, New York), Aquarius (version 4.4; TERARECON INC, Durham USA), 3mensio (Pie Medical Imaging, the Netherlands), or OSIRIX (Bernex, Switzerland) (Figure 2). All measurement were performed using totally manual or semi-automatic protocols and no artificial intelligence technologies have been described in this field.

Figure 2.

Figure 2.

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Computed tomography angiography of psoas muscle in sarcopenic and non-sarcopenic patients with abdominal aortic aneurysm.

The psoas muscle was the most frequently addressed target for the radiological evaluation. The axial slices at different boundaries of the L3 vertebrae (either at the level of the transverse processes, the proximal edge, or the distal border) have been used to outline both the right and left psoas muscle and obtain the total Psoas Muscle Area (PMA, cm2). The proximal boundary of the L4 vertebrae has also been proposed.21 Even if most Authors did not specify the reason for choosing the vertebral level, Huber et al. justified their approach by reporting a stronger Pearson’s correlation coefficient at the L4 level compared to the L3 level (0.95 vs. 0.88, respectively)13. Investigators generally defined sarcopenia using either the lowest quartile or the lowest quintile of PMA distribution in their study populations, and different threshold values have therefore been proposed, ranging between PMA <5cm2 to < 24cm2.

In order to reduce the risk of bias related to the body surface area of included patients, a normalized value of the PMA (nPMA) has been proposed, which was obtained by dividing the PMA by the square of the height (cm2/m2). Even in this scenario, there was wide variability of the reported threshold for defining sarcopenic patients, ranging between values as low as <5 cm2/m2 (as reported by Thurston et al.4) and as high as <52 cm2/m2 (as reported by Olson et al.15).

Although a number of measurement modalities have been described, a high degree of intra-observer and inter-observer agreement was detected in several studies, as reported by Waduud et al. in their comparison of 1146 blinded PMA measurements (mean difference −0.02 (0.78) cm2; P=0.669 and mean difference 0.04 (0.75) cm2; P=0.222, respectively) 14. Similar results were observed by Lindström et al. and Oliveira et al. that confirmed excellent reproducibility and prognostic value of repeated PMA measurements at L3 (intraclass correlation coefficient - ICC 0.75-1.00 and ICC >0.98, respectively ) 17–18. Inter-observer reliability of PMA scoring was acceptable even among 191 EVAR patients analyzed by Thurston et al. who reported a reproducibility coefficient as percent of mean for each observer pair: 7.92%, 7.95%, and 14.33%, respectively 4.

As for the reproducibility of thoracic sarcopenia measurement, inter- and intra-observer validation was performed among 186 TEVAR by Olson et al. revealing an ICC as high as 0.978 and 0.973, respectively 15. One issue with use of PMA as an indicator of sarcopenia is related to the composition of the muscle itself, as this value alone may be unable to reveal degenerative ‘myosteatosis’ 26. Indeed, muscle attenuation (i.e. the radiodensity) has been used to assess muscle composition in cancer patients 27-28, and low muscle attenuation has been associated with poor prognosis, regardless of the patient’s overall body weight. In order to overcome this limitation, the lean psoas muscle area (LPMA), obtained as: “(Left Psoas Area + Right psoas area)/2 x (Left attenuation + Right attenuation)/2” and expressed as cm2 x Hounsfield Units - HU) at the level of L3 or L4 vertebrae has been employed in several analyses. Three manuscripts analyzed PMA attenuation among patients who underwent aortic endovascular procedures, where sarcopenia was classified as a value of <350cm2/HU or <607cm2/HU 18,19,23. As mentioned above, a high degree of heterogeneity in the threshold values used for defining sarcopenia was evident.

Rarely, total area of multiple muscles (not only the psoas muscle) has been used for the quantitative evaluation of sarcopenia. Hale et al. established the presence or the absence of sarcopenia by the summation of the muscle areas in the abdominal wall, paraspinal and psoas groups 9. Cut-offs for sarcopenia were 114cm2 and 89cm2 for males and females respectively, adopting the same criteria for classification of donor liver transplantation patients 29. Documentation of thoracic sarcopenia in patients with thoracic aortic pathologies is relatively scarce and limited to a few studies. Olson et al. enrolled 186 patients who underwent TEVAR and they evaluated CTA including rectus abdominis, latissimus dorsi, erector spinae and oblique muscle at the level of T12 divided by body surface area (cm2/m2)15. According to the derivation and classification of thoracic sarcopenia in patients with thoracic aortic pathologies proposed by Panthotfer et al., sarcopenia was defined by thoracic skeletal muscle area<106cm2/m2 and <110cm2/m2 in females and males, respectively30.

Prognostic impact of sarcopenia in different endovascular aortic interventions

Standard EVAR

Most papers included in this analysis focused on standard EVAR (11/17). The range from those studies reporting on the prevalence of sarcopenia was between 13% and 51%. The negative effects of sarcopenia have been described by most of the reports including significantly elevated mortality risk after EVAR in sarcopenic patients, especially during mid-term and long-term follow-up. For example, among 272 patients analyzed by Cheng et al., mortality was 4% vs. 0%, 8.8% vs. 4.4% and 58% vs. 24.1% for sarcopenic vs. non-sarcopenic at 30-days, 1-year and 5-years, respectively (log-rank test, P<.0001)12. Similar results were reported by Olson et al. (19% vs. 8% at 2-years, p=.02 and 31% vs. 18% at 5-years, p=.03),15 as well as by Ikeda et al. (34% vs. 11% at 5-years, p<0.001) 21. The ratios of mortality in sarcopenic patients ranged between 2.28 (95%CI 1.35-3.84) and 6.34 (95%CI 3.37-10.0), even after adjusting for other prognostic factors (such as older age, BMI and other cardiovascular risk factors).

Among 200 EVAR procedures analyzed between 1999 and 2007 by Hale et al., patients with sarcopenia and chronic limb threatening ischemia or higher BMI revealed a significantly higher risk of overall mortality compared to non-sarcopenic patients (median follow-up 8.4 years: 76% vs. 48%, p=0.01) 9. Even the effect of chronic kidney disease in association with sarcopenia has been well established, and a lower survival rate for sarcopenic vs. non-sarcopenic patients has been demonstrated (1227 vs. 1466 days, respectively) by Thurston and colleagues among 191 elective EVAR procedures 4. The clinical relevance of sarcopenia and its association with other predictors has also been emphasized by Ito et al. in their evaluation of 310 EVARs. A prediction model that included age >75, aneurysm diameter >65mm and decreased renal function was proposed: the statistical analysis revealed that 1-year and 3-year survival rates for patients with a score of 0 points vs. those with a score of 3-4 points was 98.9% vs. 56.5% and 91.8% vs. 30.8%, respectively 16.

Sarcopenia also appeared to be a predictor for quality of life among EVAR patients. From self-reported fitness scores among 186 patients following EVAR, sarcopenic patients were more likely to report themselves as unfit for surgery when compared with their non-sarcopenic counterparts (33.3% vs. 12.4%; P = .004). Moreover, survival was poorer among sarcopenic patients (HR 2.26; P = .023) 4.

TEVAR

In 2018, Tanaka et al. retrospectively compared 34 sarcopenic vs. 37 non-sarcopenic patients who underwent TEVAR between 2007 and 2015. They reported that patients with abdominal sarcopenia (defined as a total psoas muscle index <6cm2/m2) had significantly increased adverse events compared to patients who did not have sarcopenia (41% vs. 16%, p= 0.020, respectively)11. After adjusting for multiple factors (age >70 years, p < 0.001; number of cardiovascular risk factors, p< 0.003; emergency presentation, p< 0.002), higher PMA was associated with significantly lower incidence of adverse events (OR 0.829, 95%CI 0.726–0.94, p<0.0006). While psoas-derived lumbar sarcopenia has been recognized to be a predictor of mortality after EVAR, this measurement was not predictive of long-term survival in the cohort of 200 TEVARs analyzed by Olson et al 15. Thoracic sarcopenia, on the other hand, was associated with significantly higher mortality at 2 and 5-years post-TEVAR vs. non-sarcopenic patients (2-year mortality: 19% vs. 8%, p=.02; 5-year mortality: 31% vs. 18%, p=.03), while lumbar sarcopenia was not associated with increased mortality at any point in follow-up.

Complex EVAR (CoEVAR)

The impact of sarcopenia on CoEVAR procedures was described by Kakkkainen et a.l in two different manuscripts for which LPMA was used as a surrogate for quantification of frailty 19,23. From their analysis of 244 patients enrolled in a prospective study and a retrospective analysis of 504 patients who underwent F-BEVAR for pararenal or thoracoabdominal aortic aneurysms, the authors revealed that low LPMA was a strong predictor of poor outcomes and the only independent predictor of both mortality and major adverse events. The 3-year survival estimates were 80% for low-, 70% for medium-, and 35% for high-risk patients, respectively (P< .001), while a high muscle mass was protective against complications, regardless of ASA score. Similarly, PMA was retrospectively evaluated in a single-center experience featuring 257 F/BEVARs from 2008 to 2019. Adjusted multivariable regression revealed an 8% reduction in all-cause mortality during follow-up for every 1 cm2 increase in PMA (P<0.05) and higher PMA was associated with decreased odds for 30-day mortality (HR 0.85, 95%CI 0.75–0.96, P<0.05) and spinal cord ischemia (OR 0.89, 95%CI 0.82–0.97, P<0.05). Patients with higher PMA were also less likely to be discharged to a rehabilitation center (OR 0.93, 95%CI 0.87–0.98 , P<0.05)24.

Association between sarcopenia and quality of life was also evaluated among 237 patients who underwent CoEVAR. For the 161 (66.0%) patients who returned their SF-36 instrument at 12-months, non-sarcopenic patients had significantly (p< 0.05) higher mean QoL scores at baseline and at 12-months. The largest decline in mean scores from baseline to 12-months was observed in the domain of “Physical Functioning”. At the individual level, sarcopenic patients reported a significant decrease between the baseline and 12-months postoperative domains for “Role Emotional” (p = 0.003) and “Social Functioning” (p = 0.02) compared to those who were non-sarcopenic 19.

Discussion

Sarcopenia in patients undergoing endovascular aortic surgery: summary of findings and comparison with other reviews

Scoping reviews are exploratory projects that search the literature to identify key concepts and sources of evidence that will ultimately address broader and complex exploratory research questions. Moreover, scoping reviews provide a mechanism to synthesize research evidence, especially when a universal study definition or procedure has not been firmly established. The recent growing interest in the assessment of sarcopenia and its prognostic impact in patients undergoing endovascular aortic surgery could be related to the combination of three main factors: i) patients undergoing endovascular aortic interventions are usually elderly with multiple comorbidities, which may contribute to higher prevalence of sarcopenia amongst them; ii) the dataset needed to ascertain the quality of skeletal muscle(s) is usually available at time of index procedure, thereby making assessment of sarcopenia time-effective and cost-effective; iii) there is a need to estimate life-expectancy for subjects undergoing elective repair(s), and this can explain the ongoing research for sensitive markers of long-term patients’ survival.

The main findings of our review were that, despite the heterogeneity in the methods employed for its definition which may render cross-comparison of clinical reports a challenging undertaking, sarcopenia is highly prevalent amongst patients scheduled for endovascular aortic procedures. As expected, sarcopenic patients frequently have different baseline characteristics compared with their non-sarcopenic counterparts, but the presence of sarcopenia invariably seemed to portend worse outcomes both in short and long-term follow-up. Indeed, although sarcopenia may need conclusive and uniform definition, it appears to be independently prognostic of negative late outcomes, especially in a subset of patients with very poor skeletal muscle(s) quality as evaluated on contrast-enhanced cross-sectional imaging. Nonetheless, we could not derive a validated optimal method or accurate threshold that could be recommended in clinical practice to ascertain with complete accuracy whether subjects are sarcopenic or not. Therefore, before patients are denied repair on the sole basis of sarcopenia, future prospective validation studies are highly warranted. Nonetheless, the presence of skeletal muscle sarcopenia should be seen as an indicator of poor life-expectancy and a higher clinical threshold could be favored before proceeding with the repair, considering the perceived risk of aneurysm rupture and the expected complexity of the interventional procedure. Conversely, the absence of skeletal sarcopenia should be regarded as a positive finding, thereby favoring prophylactic repair of the aortic disease when patients meet endorsed clinical practice guideline diameter thresholds. Notably, the results of our scoping review are in agreement with the available systematic reviews that have investigated the effect of low skeletal muscle mass on long-term survival among patients undergoing treatment for abdominal aortic aneurysm31. In this analysis of seven observational studies (all contained in the present report) that included 1,440 patients, Antoniou et al. showed a significant link between low skeletal muscle mass and mortality in patients undergoing open or endovascular abdominal aortic aneurysm repair but called upon future prospective research with the use of body composition as a risk prediction tool after aortic surgery. Similarly, in the work by Dakis et al, analyzing eleven observational studies (all included in the present report) for a total of 2,385 patients who underwent EVAR, the available data suggested an association between sarcopenia and worse long-term survival; however, even in this case the authors pointed out the lack of a universally accepted definition of sarcopenia and the need of future prospective studies to establish its actual negative prognostic value.32

Taken together, this scoping review of results from contemporary real-world practice corroborate findings from the historical EVAR-2 trial that reported how EVAR does not increase overall life-expectancy in patients deemed “unfit” for open AAA repair, although it may reduce aneurysm-related mortality 33. In fact, in a recent meta-analysis that included over 100,000 patients undergoing elective treatment of aortic aneurysms, long-term survival remained poor despite advances in medical care and was mainly affected by age, gender, diameter and comorbidities, all of which may be more common in patients with sarcopenia 34.

The consideration of frailty in vascular surgery is particularly important, given that the population of patients suffering from vascular disease(s) consists primarily of older adults with multiple chronic conditions and prevalent physical disabilities35. With the growth of endovascular surgery, minimally invasive options have become widely available to treat patients who would otherwise be considered to be high-risk candidates for open surgery and likely denied any repair. Incorporating frailty alongside classical clinical risk factors in the evaluation of vascular patients may improve preoperative stratification of procedural risks and anticipated benefits, thereby allowing physicians to tailor the right procedure to the right patient or, alternatively, to determine when a procedural intervention is likely to be futile36. Sarcopenia, or the substantial loss of skeletal muscles quality and mass, is a major component of frailty. Indeed, frailty and sarcopenia overlap to varying degrees in patients presenting vascular conditions and can be used alone or in combination to predict long-term survival of older patients37. Many frailty scoring tools are currently available, although there is no consensus on when and which scoring features to use. The European Working Group on Sarcopenia in Older People (EWGSOP) defines sarcopenia as “a syndrome characterized by progressive and generalized muscle mass and strength loss in association with low quality of life, physical disability and increased death risk” 38. Indeed, low skeletal muscle mass has been shown to be a strong predictor for worse post-operative outcomes in patients undergoing major surgery, in the short-term as well as in the mid- to long-term 39, 40, independent of any sex stratification.

Treatment of sarcopenia

In addition to its potential prognostic role and risk stratification in surgical patients, sarcopenia may be a modifiable frailty parameter, offering the potential role of pre-habilitation and targeted interventions to optimize patient health and fitness prior to major surgery. To date, interventional approaches to treat sarcopenia in older adults have not been standardized 41. This was highlighted in two recent systematic reviews, pointing out that few studies exist regarding the effects of nutritional management of inpatients with sarcopenia. 42, 43. For that matter, any association between successful reversal of sarcopenia and outcomes is unknown.

Current controversies, Implications for practice, and Future directions of research

As noted above, patients with low skeletal muscle mass have a significantly higher hazard of mortality than those without low skeletal muscle mass. However, we have also highlighted substantial heterogeneity regarding the methodology used to assess skeletal muscle mass and the thresholds adopted to identify sarcopenic patients, independent of sex stratification. Although the relationship between psoas muscle sarcopenia and worse long-term survival can be reasonably inferred, using this information as a predictive tool remains a challenge. In their work, Paajanen and colleagues have suggested using the combination of traditional cardiovascular risk assessment (ASA score) together with radiographically quantified sarcopenia to help identify high-risk patients with poor predicted long-term survival. In the recent systematic review with time-to-event meta-analysis by Antoniou et al., restricted to patients undergoing AAA repair, a significant link between low skeletal muscle mass and mortality was identified31. However, the heterogeneity across studies led the authors to conclude that further prospective studies validating the use of body composition for risk prediction after aortic surgery are still required before this tool can be used to support decision-making and patient selection. It may be that low quality and/or low mass of the psoas muscles could be integrated with other biomarkers (such as significant preoperative renal function impairment44, 45) to develop risk prediction tools that may assist clinicians in the decision-making progress.

The rationale for the direct relationship between sarcopenia and age is both intuitive and biologically based upon the observed loss of skeletal muscle mass that occurs with aging. However, the association of sarcopenia with sex is still controversial and whether the same threshold for definition of sarcopenia should be used in men and women remains unaddressed and deserves further considerations. Even the role of BMI is still controversial and there is substantial evidence that the relationship between BMI and mortality in cardiovascular patients is not linear, but more ‘U-shape’. A meta-analysis of 12,715 patients undergoing coronary artery bypass grafting showed that the operative risk was lowest for patients with a BMI of approximately 30 kg/m2 and highest for those with a BMI <20 kg/m2 and >40 kg/ m2 46. Moreover, several nutritional risk indices are available, but none validated in vascular patients and their relationship with sarcopenia also remains an area of potential investigation.

As cross-sectional imaging is an essential part of the pre-operative work up for patients with aortic disease who are scheduled for endovascular interventions, measurements of skeletal muscle cross section is possible in most cases. This is also true for patients scheduled to undergo TEVAR, as their preoperative planning should always include cross-sectional imaging of the abdomen/pelvis to evaluate for potential issues with iliofemoral access. Defining and validating universally accepted thresholds for PMA would be helpful as (or within) a risk prediction model especially in cases of uncertainty of survival advantage from elective treatment of aortic disease. A universally accepted definition and measurement method for low skeletal muscle mass is required to achieve these goals, and large, well-conducted prospective studies validating the use of body composition for risk prediction after aortic surgery are required before this tool can be widely used to support decision-making and patient selection. Such studies may incorporate targeted analyses based on gender, as well as measures of quality of life and cost-effectiveness in order to obtain a more holistic approach to understanding these complex phenomena5. Lastly, an area of future investigation includes analysis of interventions targeted at reversal of sarcopenia so that this may (at least partly) mitigate its negative prognostic impact.

Study limitations

Given the scoping nature of this review, there is an element of selection bias in the identification of articles for inclusion. Relevant articles may also have been missed using the search parameters and literature search. This review presents heterogenous study designs and methods; furthermore, there was a variety of definitions used for the post-operative outcomes assessed as well as length of follow-up for included studies. This makes it difficult to generalize findings to all patients undergoing endovascular repair for aortic aneurysmal disease. Pooled analyses are particularly useful for scenarios in which existing evidence arises primarily from small studies that are underpowered to detect statistically significant differences, but in this review, heterogeneity among included studies precluded pooled analysis.

Conclusions

Sarcopenia, as identified using CTA-based measurements of skeletal muscle mass, is frequently observed in patients undergoing EVAR, TEVAR or CoEVAR. The presence of sarcopenia has been shown to carry a negative prognostic impact and linked to poorer long-term survival. Therefore, its assessment might become a highly convenient and valid adjunctive tool that could complement the risk-stratification process of patients who are candidates for endovascular repair of aortic diseases. Future studies should investigate the optimal methodology and thresholds that should be used in clinical practice, in addition to a better understanding of whether and how the management of sarcopenia may improve resource utilization and, more importantly, clinical outcomes.

Article Highlights.

Type of Research.

Scoping review of the literature.

Key Findings.

Sarcopenia, as identified using CTA-based measurements of skeletal muscle mass, can be frequently found in patients undergoing elective EVAR, TEVAR or F-BEVAR. Presence of sarcopenia has been shown to have a negative prognostic impact and linked to poorer long-term survival.

Take Home Message.

Radiological assessment of skeletal muscle sarcopenia might become a useful adjunctive tool that could complement the risk-stratification process of patients who are candidates for elective endovascular repair of aortic diseases. Future studies should investigate the optimal methodology and thresholds that should be used in clinical practice, with the hope to provide a fuller understanding of how the recognition and management of sarcopenia may improve clinical outcomes and resource utilization

Fundings:

None.

Footnotes

Publisher's Disclaimer: This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Conflicts of Interest: None.

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