External validation of CLI Frailty Index and assessment of predictive value of modified CLI Frailty Index for patients with critical limb ischemia undergoing infrainguinal revascularization

Abstract

Objectives CLI Frailty is a useful diagnostic criterion of frailty in patients with critical limb ischemia (CLI). It is important to evaluate not only comorbidities but also frailty in decision making to select the type of treatment for CLI patients. The purposes of our study were to externally validate the CLI Frailty Index and to evaluate the modified CLI Frailty Index by measurement of skeletal muscle mass using computed tomography. Methods Patients who underwent preoperative computed tomography examination and infrainguinal revascularization between 2002 and 2015 were retrospectively analyzed. A patient was defined as CLI Frailty (+), if two or more of the following criteria were present: low Geriatric Nutritional Risk Index (GNRI), low skeletal muscle mass index (SMI) evaluated by prediction equations, and non-ambulatory status. For the modified CLI Frailty Index, skeletal muscle area was measured by computed tomography instead of prediction equations. Results During the study period, 226 patients with CLI underwent revascularization; we included 127 patients and excluded 99 patients who were treated only with iliac revascularization or did not undergo CT scans. The overall survival at two years after revascularization was 83.6% for the CLI Frailty (−) group versus 63.2% for the CLI Frailty (+) group ( P = .02). The overall survival at two years after revascularization was 89.7% for the modified CLI Frailty (−) group versus 60.5% for the modified CLI Frailty (+) group ( P < .01). Multivariate analysis 1 including CLI Frailty revealed that hemodialysis (HR, 3.71; 95% CI, 1.58–8.83; P < .01), CLI Frailty (HR, 3.22; 95% CI, 1.35–7.47; P < .01) and cerebrovascular disease (HR, 2.58; 95% CI, 1.09–5.91; P = .03) were risk factors for overall survival two years after revascularization. In multivariate analysis 2 including modified CLI Frailty, modified CLI Frailty (HR, 5.92; 95% CI, 2.49–15.7; P < .01), hemodialysis (HR, 4.03; 95% CI, 1.65–10.0; P < .01) and diabetes mellitus (HR, 0.41; 95% CI, 0.16–0.99; P = .05) were risk factors for overall survival two years after revascularization. Conclusions Both the CLI Frailty and the modified CLI Frailty Indexes were useful in predicting the two-year overall survival of patients with CLI after infrainguinal revascularization. Although the measurement of skeletal muscle mass using computed tomography may accurately predict two-year overall survival, SMI prediction is effective for patients with CLI who did not undergo preoperative CT.

The Rise of Mitochondria in Peripheral Arterial Disease Physiopathology: Experimental and Clinical Data

“…These conflicting findings could be explained by disparities in disease severity. Indeed, the alterations in mitochondrial oxidative capacity may have been the result of factors associated with higher morbidity in PAD, such as sarcopenia [33][34][35].…”

Sarcopenia and peripheral arterial disease: a systematic review

“…Indeed, in 2015, and subsequently in 2017, Matsubara et al reported that sarcopenia was associated with higher cardiovascular events and lower survival, in 64 and 114 patients suffering from CLI, respectively. 22,23 Recent papers confirmed this association in retrospective studies including patients with CLI, where low skeletal muscle mass was predictive of a worse overall survival [24][25][26] Figure 2).…”

“…Data extraction led to the evaluation of 140 publications, of which 87 met the inclusion criteria, and 79 were included in the final review. Of these, 18 gave sufficient data for epidemiological analysis and diagnostic criteria, [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] 33 gave sufficient data for mechanistical analysis, and 28 gave sufficient data for therapeutic approaches. 1/Epidemiological data: Is sarcopenia a rare condition in patients with PAD?…”

Associations of Clinical Frailty with Severity of Limb Threat and Outcomes in Chronic Limb-threatening Ischaemia

“…8,10 Ongoing research may provide further useful information regarding assessment of frailty, physical function and cognitive impairment, as well as other outcomes such as quality of life and durability of revascularisation, in patients with CLTI. 34 Previous research has also demonstrated associations with frailty and outcomes over ≥1 year 3,4,[35][36][37] associated with worse overall survival and AFS at two-years, adjusting for tissue loss in their multivariable model. 3 Using the critical limb ischaemia (CLI) frailty index, a novel three-item frailty score, Morisaki et al (266 patients) showed an independent association of frailty with worse overall survival and AFS.…”

“…35 However, their follow-up study (127 patients) showed only an independent association with overall survival, and the CLI frailty index is only validated to predict risk, not its ability to identify frailty. 10,35,36 Soon et al (233 patients) used the modified frailty index (mFI) and also found an association of frailty with worse one-year mortality but not major amputation in CLTI. 37 However, the utility of the mFI as a frailty tool has been questioned.…”