Psoas Major muscle area as a prognostic marker in peripheral arterial disease: a systematic review and meta-analysis

Although frailty and reduced muscle mass are known to worsen surgical outcomes, the prognostic value of psoas major morphometry in peripheral arterial disease (PAD) remains incompletely defined. Sarcopenia, frequently quantified through cross-sectional psoas major muscle area on preoperative imaging, has emerged as a potential prognostic marker in patients undergoing lower-limb revascularization for PAD. This systematic review and meta-analysis aimed to evaluate whether reduced psoas major muscle area is associated with short- and long-term mortality following revascularization.

A systematic search of MEDLINE, Scopus, and Web of Science identified observational studies assessing psoas muscle morphometrics in adults undergoing surgical or endovascular revascularization for PAD. Seven retrospective cohort studies (n = 2,290 patients) met the inclusion criteria. Study quality was assessed using the NHLBI tool. Random-effects meta-analyses were performed for 1-month and 1-year mortality. Heterogeneity was evaluated using I², and prediction intervals were calculated. Due to the small number of studies, meta-regression was not performed.

Three studies contributed to the 1-month mortality analysis. The pooled estimate suggested a possible increase in early mortality among sarcopenic patients with a smaller psoas major area, but the association was not statistically significant (RR = 2.45; 95% CI 0.58-10.36; I ² = 38.3%; p = 0.22). Five studies reported 1-year mortality, demonstrating a significant association between reduced psoas major muscle area and increased long-term mortality (RR = 2.37; 95% CI 1.51-3.73; I ² = 43.4%; p < 0.001). Although point estimates remained directionally consistent across heterogeneous imaging methodologies and sarcopenia definitions, confidence intervals were wide, and the prediction interval for 1-year mortality crossed the null value, indicating uncertainty regarding the magnitude and consistency of the association across future settings. Insufficient data prevented quantitative synthesis of limb outcomes.

A reduced psoas major muscle area was associated with increased 1-year mortality in patients undergoing lower-limb revascularization for PAD, supporting a potential role for psoas morphometry as a prognostic marker of long-term vulnerability. Although short-term mortality findings were inconclusive due to limited power, psoas morphometry may have value in preoperative risk stratification. Standardized definitions and prospective studies are needed before routine clinical integration can be recommended and to clarify whether targeted nutritional and rehabilitation strategies may improve outcomes.

identifier CRD420251118644, https://www.crd.york.ac.uk/PROSPERO/view/CRD420251118644.