Objective: Frailty, a clinical syndrome associated with loss of metabolic reserves, is prevalent among patients who present to vascular surgery clinics for evaluation. The Clinical Frailty Scale (CFS) is a rapid assessment method shown to be highly specific for identifying frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to predict loss of independence after major vascular procedures. Methods: We identified all patients living independently at home who were prospectively assessed using the CFS before undergoing an elective major vascular surgery procedure (admitted for >24 hours) at an academic medical center between December 2015 and December 2017. Patient-and procedure-level clinical data were obtained from our institutional Vascular Quality Initiative registry database. The composite outcome of discharge to a nonhome location or 30-day mortality was evaluated using bivariate and multivariate regression models. Results: A total of 134 independent patients were assessed using the CFS before they underwent elective open abdominal aortic aneurysm repair (8%), endovascular aneurysm repair (26%), thoracic endovascular aortic repair (6%), suprainguinal bypass (6%), infrainguinal bypass (16%), carotid endarterectomy (19%), or peripheral vascular intervention (20%). Among 39 (29%) individuals categorized as being frail using the CFS, there was no significant difference in age or American Society of Anesthesiologists physical status compared with nonfrail patients. However, frail patients were significantly more likely to need mobility assistance after surgery (62% frail vs 22% nonfrail; P < .01) and to be discharged to a nonhome location (22% frail vs 6% nonfrail; P ¼ .01) or to die within 30 days after surgery (8% frail vs 0% nonfrail; P < .01). Preoperative frailty was associated with a >12-fold higher risk (odds ratio, 12.1; 95% confidence interval, 2.17-66.96; P < .01) of 30-day mortality or loss of independence, independent of the vascular procedure undertaken. Conclusions: The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective major vascular surgery and can be used to predict likelihood of requiring discharge to a nursing facility or death after surgery. The identification of frail patients before major surgery can help manage postoperative expectations and optimize transitions of care.

We identified all patients who underwent an open thrombectomy procedure for a thrombosed AV fistula or PTFE graft at a single academic medical center between January 2006 and March 2017. The specific type of AV fistula or graft was evaluated as well as patient demographics, comorbidities, medications, and interventions performed to maintain fistula patency. The primary outcome measuresdsuccessful dialysis after thrombectomy and time to recurrent thrombosisdwere analyzed using Kaplan-Meier and Cox regression models.Results: During the study period, 221 thrombectomy procedures were performed in 160 patients (mean age 52 years, 60% female), of which 82 (37%) were undertaken in AV fistulas and 139 (63%) in AV grafts. Patients with AV fistulas (24% radiocephalic, 42% brachiocephalic, and 34% brachiobasilic), were less likely to be diabetic or have ischemic heart disease (both P < .05) as patients with AV grafts but just as likely to be on antiplatelet or statin agents. After thrombectomy, there was no difference in use of adjuvant interventions to maintain patency (67% fistula vs 73% graft; P ¼ .4), and an equal number of patients in both groups dialyzed successfully (62% fistula vs 55% graft; P ¼ .3) at least once. However, rates of recurrent thrombosis at 1 year were significantly lower for AV fistulas vs grafts (P < .05; Fig), which was confirmed in multivariate analysis where AV fistulas had a 37% lower risk of failure (hazard ratio, 0.63; 95% confidence interval, 0.43-0.93; P < .05) after controlling for confounders.Conclusions: Our data suggest that AV fistula thrombectomy is successful in nearly two-thirds of cases, with improved long-term outcomes compared with PTFE grafts. While the risk of access failure is high after thrombectomy, efforts to salvage AV fistulas are effective in most patients and should be undertaken when feasible.