Computed tomography -defined sarcopenia is associated with long-term survival among patients undergoing open thoracic aortic reconstruction.

BACKGROUND AND OBJECTIVE: As markers of sarcopenia, psoas muscle areas and indexes measured from computed tomography images have been found to predict long-term mortality in cardiothoracic as well as other surgical cohorts. Our objective was to investigate the association between psoas muscle status, taking into account muscle density in addition to area, and survival among patients undergoing open thoracic aortic reconstruction. METHODS: This was a retrospective registry study of a total of 451 patients treated with open surgery for thoracic aortic pathology. Psoas muscle area and density were measured from preoperative computed tomography images at the L3 and L4 lumbar levels. In addition, lean psoas muscle area was calculated by averaging sex-specific values of psoas muscle area and density. The association between mortality and psoas muscle status was analyzed with adjusted Cox-regression analysis. RESULTS: The median age of the study population was 63 (interquartile range (IQR): 53-70) years. The majority were male (74.7%, n = 337) and underwent elective procedures (58.1% n = 262). Surgery of the ascending aorta was carried out in 90% of the patients, and 15% (n = 67) had concomitant coronary artery bypass surgery. Aortic dissection was present in 34.6% (n = 156) patients. Median follow-up time was 4.3 years (IQR: 2.2-7.4). During the follow-up, 106 patients (23.5%) died, with 55.7% of deaths occurring within the first four postoperative weeks. Psoas muscle parameters were not associated with perioperative mortality, but significant independent associations with long-term mortality were observed for psoas muscle area, density, and lean psoas muscle area with hazard ratios (HRs) of 0.63 (95% confidence interval (CI): 0.45-0.88), 0.62 (95% CI: 0.46-0.83), and 0.47 (95% CI: 0.32-0.69), respectively (all per 1-SD increase). CONCLUSIONS: Psoas muscle sarcopenia status is associated with long-term mortality after open thoracic aortic surgery.

Psoas muscle quantified muscle status and long-term mortality after cardiovascular interventions.

RESULTS: In the meta-analysis, psoas muscle measurements were significantly associated with mortality among men (p < 0.05), with high heterogeneity in the associations across all cohorts. There was very little difference in the association between PMA and PMD and mortality (HR 0.83, 95% CI 0.69-0.99, p = 0.002; HR 0.85, 95% CI 0.77-0.94, p = 0.041 for one SD increase in PMA and PMD in the random effects model). Combining PMA and PMD into one composite variable by multiplying their values together showed the most robust association in terms of the magnitude of the effect size in men (HR, 0.77; 95% CI 0.73-0.87, p < 0.001). Indexing PMA to body size did not result in any significant differences in this association. Among women, psoas muscle measurements were not associated with long-term mortality in this meta-analysis. CONCLUSIONS: Different psoas muscle measurements were significantly and very similarly associated with mortality among men but not among women. No single measurement stands out, although combining PMA and PMD seems to be a slightly stronger estimate in terms of effect size and should be considered in further studies.

Significant sarcopenia affecting survival in patients undergoing heavy invasive operations may be preoperatively assessed using images of psoas muscle (PM) from routine computerized tomography but the optimal method for evaluation is unclear. A meta-analysis of individual participant data of over two thousand patients undergoing cardiovascular interventions shows that different PM measurements of surface area and density were significantly and very similarly associated with mortality among men but not among women. Combining PM area with PM density to one estimate of lean psoas muscle area seems to provide the strongest hazard estimate among men.

Multivariable Analysis of Pre-operative Brain Atrophy as a Predictor of Long Term Mortality After Carotid Endarterectomy.

OBJECTIVE: Brain atrophy is associated with an increased mortality rate in elderly trauma patients and in patients treated with mechanical thrombectomy for acute ischaemic stroke. In the setting of ischaemic stroke, the association between brain atrophy and death is stronger than that of sarcopenia. It has previously been shown that lower masseter area, as a marker of sarcopenia, is linked to lower survival after carotid endarterectomy (CEA). The aim of this study was to investigate whether brain atrophy is also associated with long term mortality in patients undergoing CEA. METHODS: A cohort of patients treated with CEA between 2004 and 2010 was retrieved from the Tampere University Hospital vascular registry and those with available pre-operative computed tomography (CT) imaging were analysed retrospectively. CT images were evaluated for brain atrophy index (BAI) and masseter muscle surface area and density. The association between BAI and mortality was investigated with Cox regression. RESULTS: Two hundred and thirty-three patients with a median (interquartile range [IQR]) age of 71 years (64.0, 77.0) were included. Most patients were operated on for symptomatic stenosis (n = 203; 87.1%). The median (IQR) duration of follow up was 115.0 months (66.0, 153.0), and 155 patients (66.5%) died during follow up. BAI was statistically significantly correlated with age (r = .489), average masseter density (r = -.202), and smoking (r = -.186; all p <.005). Increased BAI was statistically significantly associated with overall mortality (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.25 - 1.68, per one standard deviation [SD] increase) in the univariable analysis, and the association remained (HR 1.23, 95% CI 1.04 - 1.46, per one SD increase) in the multivariable models. Age, peripheral artery disease, and chronic obstructive pulmonary disease were also independently associated with mortality. The optimal cutoff value for BAI was 0.133. CONCLUSION: Brain atrophy independently predicts the long term post-operative mortality rate after CEA in a cohort containing mainly symptomatic patients. Future studies are needed to validate the results in prospective settings and in asymptomatic patients.

Radiographically quantified sarcopenia and traditional cardiovascular risk assessment in predicting long-term mortality after endovascular aortic repair.

OBJECTIVE: This study evaluated radiographically quantified sarcopenia and the patient's comorbidity burden based on traditional cardiovascular risk assessment as potential predictors of long-term mortality after endovascular aortic repair (EVAR). METHODS: The study included 480 patients treated with standard EVAR for intact infrarenal abdominal aortic aneurysms. Patient characteristics, comorbidities, aneurysm dimensions, and other preoperative risk factors were collected retrospectively. Preoperative computed tomography was used to measure psoas muscle area (PMA) at the L3 level. Patients were divided into three groups based on American Society of Anesthesiologists (ASA) score and PMA. In the high-risk group, patients had sarcopenia (PMA <8.0 cm2 for males and <5.5 cm2 for females) and an ASA score of 4. In the medium-risk group, patients had either sarcopenia or an ASA score of 4. Patients in the low-risk group had no sarcopenia and the ASA score was less than 4. Risk factors for long-term mortality were determined using multivariable analysis. Kaplan-Meier survival estimates were calculated for all-cause mortality. RESULTS: Patients in the high- and medium-risk groups were older than those in the low-risk group (77 ± 7, 76 ± 6, and 74 ± 8 years, respectively, P < .01). Patients in the high-risk group had higher prevalence of coronary artery disease, pulmonary disease, and chronic kidney disease. There were no differences in 30-day or 90-day mortality between the groups. The independent predictors of long-term mortality were age, ASA score, PMA, chronic kidney disease, and maximum aneurysm sac diameter. The estimated 1-year mortality rates were 5% ± 2% for the low-risk, 5% ± 2% for the medium-risk, and 18% ± 5% for the high-risk group (P < .01). Five-year mortality estimates were 23% ± 4%, 36% ± 3%, and 60% ± 6%, respectively (P < .01). The mean follow-up time was 5.0 ± 2.8 years. CONCLUSIONS: Both ASA and PMA were strong predictors of increased mortality after elective EVAR. The combination of these two can be used as a simple risk stratification tool to identify patients in whom aneurysm repair or the intensive long-term surveillance after EVAR may be unwarranted.

Statin use, development of sarcopenia, and long-term survival after endovascular aortic repair.

OBJECTIVE: Statin therapy, associated with improved short-term survival after treatment of abdominal aortic aneurysms, may also predispose to muscle side effects. Evidence on statin-related sarcopenia is limited mainly to muscle function, and it is subject to several sources of bias. In the long term, postoperative development of sarcopenia is linked to mortality after endovascular repair (EVAR). We investigated statin use and long-term postoperative mortality after EVAR in relation to objective measurable markers of sarcopenia (psoas muscle surface area and density). METHODS: Altogether 216 abdominal aortic aneurysm patients treated with EVAR between 2006 and 2014 at Tampere University Hospital (Finland) were retrospectively studied. Psoas muscle parameters at the L3 level were evaluated from baseline and mainly 1- to 3-year follow-up computed tomography studies. Cox regression was used to study the association between statin medication, psoas muscle changes, and all-cause mortality. RESULTS: The majority of patients were male (87%), and the mean age was 77.7 years (standard deviation, 7.4). The median duration of follow-up was 6.3 years (interquartile range, 3.5) with a total mortality of 54.2% (n = 117). Regardless of a higher burden of comorbidities, statin users (n = 119) had lower mortality when compared with nonusers (multivariable hazard ratio [HR]: 0.69, 95% confidence interval: 0.48-0.99, P = .048). Furthermore, statin use was not associated with inferior muscle parameter values, and the relative change in psoas muscle area was actually lower in statin users compared with nonusers (-15.7% and -21.1%, P < .046). CONCLUSIONS: Statin use is associated with lower long-term mortality among patients undergoing EVAR without predisposing to increased sarcopenia.

Association of masseter area and radiodensity with three-month survival after proximal anterior circulation occlusion.

BACKGROUND: Masseter area (MA), a surrogate for sarcopenia, appears to be useful when estimating postoperative survival, but there is lack of consensus regarding the potential predictive value of sarcopenia in acute ischemic stroke (AIS) patients. We hypothesized that MA and density (MD) evaluated from pre-interventional CT angiography scans predict postinterventional survival in patients undergoing mechanical thrombectomy (MT). MATERIALS AND METHODS: 312 patients treated with MT for acute occlusions of the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (M1-MCA) between 2013 and 2018. Median follow-up was 27.4 months (range 0-70.4). Binary logistic (alive at 3 months, OR <1) and Cox regression analyses were used to study the effect of MA and MD averages (MAavg and MDavg) on survival. RESULTS: In Kaplan-Meier analysis, there was a significant inverse relationship with both MDavg and MAavg and mortality (MDavg P<0.001, MAavg P=0.002). Long-term mortality was 19.6% (n=61) and 3-month mortality 12.2% (n=38). In multivariable logistic regression analysis at 3 months, per 1-SD increase MDavg (OR 0.61, 95% CI 0.41 to 0.92, P=0.018:) and MAavg (OR 0.57, 95% CI 0.35 to 0.91, P=0.019) were the independent predictors associated with lower mortality. In Cox regression analysis, MDavg and MAavg were not associated with long-term survival. CONCLUSIONS: In acute ischemic stroke patients, MDavg and MAavg are independent predictors of 3-month survival after MT of the ICA or M1-MCA. A 1-SD increase in MDavg and MAavg was associated with a 39%-43% decrease in the probability of death during the first 3 months after MT.

Brain atrophy predicts mortality after mechanical thrombectomy of proximal anterior circulation occlusion.

BACKGROUND: Brain atrophy is associated with an inferior functional outcome in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke. We hypothesized that brain atrophy determined from pre-interventional non-contrast-enhanced CT scans would also be linked to increased mortality in this cohort. METHODS: A total of 204 patients treated with MT for acute occlusions of the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (M1) at Tampere University Hospital, Finland between 2013 and 2017 were retrospectively studied. Brain atrophy index (BAI), masseter muscle surface area and density, chronic ischemic lesions, and white matter lesions were evaluated from pre-interventional CT studies. Logistic regression was applied in analyzing the association of BAI with 3-month mortality. RESULTS: Median age at baseline was 69.9 years (IQR 15.6) and mortality at 3 months was 13.2% (n=27). BAI, measured with excellent reproducibility (intraclass correlation coefficient ≥0.894, p<0.001), was significantly associated with age (r=0.54), white matter lesions (r=0.43), dental status (r=-0.31), masseter area (r=-0.24), masseter density (r=-0.28), and chronic ischemic lesions (r=0.24) (p≤0.001 for all). In univariable analysis, BAI demonstrated a strong association with mortality (OR 2.02, 95% CI 1.34 to 3.05, per 1 SD increase), and none of the other factors associated with mortality remained as significant when included in the same multivariable model. The results remained similar when extending the follow-up up to 2.5 years. CONCLUSIONS: Brain atrophy predicts 3-month mortality after MT of the ICA or the M1 independent of age, masseter sarcopenia, chronic ischemic lesions, or white matter lesions.

Developing sarcopenia predicts long-term mortality after elective endovascular aortic aneurysm repair.

BACKGROUND: Preoperatively detected sarcopenia as reflected by psoas muscle area (PMA) is associated with postoperative mortality after abdominal aortic aneurysm (AAA) repair. We studied, whether changes in PMA and lean PMA (LPMA) after endovascular aortic repair (EVAR) are associated with postoperative survival. METHODS: In 122 AAA patients treated between 2008 and 2016 (90% male; median age, 77.8 years; interquartile range, 11.5; rupture 2.5%) PMA and LPMA at L3 level were measured retrospectively from preoperative and 1- and 3-year follow-up computed tomography (CT) studies. The median duration of follow-up was 6.0 years (interquartile range, 3.5) and all-cause mortality was 46.7%. Association of radiologic muscle parameters with all-cause mortality was evaluated with Cox regression. Clinical data were collected from an institutional database and patient record databases. RESULTS: There was a significant decrease in PMA and LPMA at L3 level (mean, -4.4 cm2 [-26.8%] for PMA and -130.4 cm2 × Hounsfield units [-21.6%] for LPMA, respectively; P < .001) and the greatest decline occurred during the first postoperative year after EVAR. Relative PMA change during follow-up (ΔPMA/baseline CT muscle parameter) was independently associated with mortality in multivariable analysis (hazard ratio, 0.977 for a 1% unit increase; 95% confidence interval, 0.960-0.995; P = .011). CONCLUSIONS: The most significant loss of skeletal muscle occurs during the first year after EVAR. The relative change in PMA from baseline is an independent predictor of mortality. For every 10% unit increase in ΔPMA/baseline CT muscle parameter bilaterally, there was a 21% decrease in the probability of death during follow-up. Early detection (from CT studies) and prevention of sarcopenia may potentially improve survival in EVAR-treated patients.

Psoas Muscle Area and Quality Are Independent Predictors of Survival in Patients Treated for Abdominal Aortic Aneurysms.

BACKGROUND: Sarcopenia is associated with mortality after abdominal aortic aneurysm (AAA) repair. The reliability of computed tomography (CT) core muscle areas and quality-that is, densities and their association with postoperative survival in patients undergoing AAA treatment-were retrospectively studied. METHODS: Psoas muscle area (PMA) and multifidus area and psoas muscle density (PMD) and multifidus density were measured from CT images and analyzed to lean values. Results were standardized by z-scoring. Measurement reliability was ascertained using intraclass correlation coefficient analysis (3 independent observers). Clinical data were collected from an institutional database and the hospital's patient record database. RESULTS: The study included 301 patients (89% male, mean age 74.4 years, endovascular treatment 73.1%, rupture 7.6%). Median duration of follow-up was 2.70 (interquartile range 3.54) years and mortality 31.2%. Age, female gender, and body mass index were associated with PMA, PMD, and lean psoas muscle area (LPMA). L3 left PMD, total psoas muscle density, right and left LPMA, lean total psoas muscle area (LTPMA), and L2 right LPMA and LTPMA (hazard ratio 0.74-0.78 per 1 standard deviation, P < 0.05 to P < 0.01) were independently associated with improved survival in multivariable analysis. CONCLUSIONS: L2-L3 PMD and LPMA are reliable, feasible, and independent predictors of mortality in patients treated for AAA. For every standard deviation increase in these standardized z-score muscle parameters, there was a 22%-26% decrease in the probability of death during follow-up.

Pre-Operative Masseter Area is an Independent Predictor of Long-Term Survival after Carotid Endarterectomy.

OBJECTIVE/BACKGROUND: Sarcopenia is a predictor of mortality in elderly patients. Masseter area (MA) reflects sarcopenia in trauma patients. It was hypothesised that MA and Masseter density (MD) could be evaluated reliably from pre-operative computed tomography angiography (CTA) scans and that they predict post-operative survival in carotid endarterectomy (CEA) patients. METHODS: This was an observational registry study. Patients (n = 242) were operated on for asymptomatic stenosis (n = 32; 13.2%), amaurosis fugax (n = 41; 16.9%), transient ischaemic attack (n = 85; 35.1%), or ischaemic stroke (n = 84; 34.7%). Internal carotid artery stenoses were graded angiographically. Intraclass correlation coefficient (ICC) was used to analyse measurement reliability by three independent observers. Cox regression analysis was used to study the effect of MA and MD on survival (hazard ratio [HR]). RESULTS: Median patient age was 71.0 years (interquartile range [IQR] 13.0) and follow up time was 68.5 months (range 3-163 months); at the end of follow up (1 October 2017), 104 (43.0%) patients had died according to the National Population Register. The average MA (MAavg, the mean of left and right MA [median 394.0 mm2; IQR 110.1 mm2]) and MD (MDavg, the mean of left and right MD [median 53.5 HU; IQR 16.5 HU]) could be measured with excellent reliability (ICC > 0.865, p < .001 for all). In multivariable analyses only body surface area (BSA) (p < .001) and dental status were associated with MAavg (p = .021). Increased MAavg predicted lower mortality (HR 0.76, 95% confidence interval [CI] 0.61-0.96; p = .023) independent of age (HR 1.05, 95% CI 1.02-1.07; p = 0.001), female sex, body mass index, renal insufficiency, ipsilateral stenosis, indication category, and presence of teeth. MDavg was not associated with mortality. After further adjustment, BSA (the most significant determinant of MAavg) did not alter the association between MAavg and mortality (0.75, 95% CI 0.58-0.97; p = .031). CONCLUSION: Average MA but not MD measured from the pre-operative CTA scan provides a reliable estimate of post-operative long-term survival in CEA patients independent of other risk factors, anthropometric measurements, and dental status.