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The Concept of Risk Assessment and Being Unfit for Surgery
P Kolh1, S De Hert2, P De Rango3
1Cardiovascular Surgery Department, University Hospital (CHU, ULg) of Liège, Belgium.
Insights
Identifying high-risk patients for vascular surgery requires a clear, quantified approach. This review suggests a practical, step-by-step method to define and stratify surgical risk, addressing current gaps in patient selection.
Area of Science:
- Vascular Surgery
- Geriatric Medicine
- Surgical Risk Assessment
Background:
- The increasing complexity and volume of minimally invasive vascular surgery necessitate improved patient selection.
- Current definitions of surgical unfitness and high-risk criteria for vascular procedures are not standardized or consistently updated.
- Existing predictive risk scores often lack generalizability due to gaps in defining high-risk vascular patients.
Purpose of the Study:
- To propose a practical, step-by-step approach for assessing surgical risk in vascular interventions.
- To highlight the need for updated, objective definitions of surgical unfitness in the evolving field of vascular surgery.
- To emphasize the importance of incorporating frailty and geriatric assessments into surgical risk stratification.
Main Methods:
- A review of current concepts in surgical risk assessment for vascular interventions.
- A proposed three-step, two-point approach for defining, quantifying, and stratifying surgical risk.
- Inclusion of patient-specific factors like life expectancy, goals, and geriatric burden (frailty, cognitive, functional, social, nutritional status).
Main Results:
- A structured, step-by-step process for identifying and stratifying high-risk vascular surgery patients is outlined.
- The review identifies significant gaps in the current literature regarding standardized definitions of surgical unfitness.
- Traditional high-risk criteria are evolving, necessitating a broader assessment beyond peri-operative mortality.
Conclusions:
- A more refined, multi-faceted approach to surgical risk assessment is crucial for vascular interventions, especially in elderly and complex patients.
- Integrating geriatric assessments and patient-centered goals is essential for accurate risk stratification and informed surgical decisions.
- Standardized definitions and validated predictive tools are needed to improve patient selection and outcomes in vascular surgery.
Abstract:
The concept of risk assessment and the identification of surgical unfitness for vascular intervention is a particularly controversial issue today as the minimally invasive surgical population has increased not only in volume but also in complexity (comorbidity profile) and age, requiring an improved pre-operative selection and definition of high risk. A practical step by step (three steps, two points for each) approach for surgical risk assessment is suggested in this review. As a general rule, the identification of a "high risk" patient for vascular surgery follows a step by step process where the risk is clearly defined, quantified (when too "high"?), and thereby stratified based on the procedure, the patient, and the hospital, with the aid of predictive risk scores. However, there is no standardized, updated, and objective definition for surgical unfitness today. The major gap in the current literature on the definition of high risk in vascular patients explains the lack of sound validated predictive systems and limited generalizability of risk scores in vascular surgery. In addition, the concept of fitness is an evolving tool and many traditional high risk criteria and definitions are no longer valid. Given the preventive purpose of most vascular procedures performed in elderly asymptomatic patients, the decision to pursue or withhold surgery requires realistic estimates not only regarding individual peri-operative mortality, but also life expectancy, healthcare priorities, and the patient's primary goals, such as prolongation of life versus maintenance of independence or symptom relief. The overall "frailty" and geriatric risk burden, such as cognitive, functional, social, and nutritional status, are variables that should be also included in the analyses for stratification of surgical risk in elderly vascular patients.
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