Prognostic Value of Frailty in Chronic Limb-Threatening Ischemia (CLTI) Revascularization: A Systematic Review and Meta-Analysis.

INTRODUCTION Frailty is an important predictor of adverse outcomes in vascular surgery, but its prognostic value after lower extremity revascularization for peripheral artery disease (PAD) remains uncertain. This systematic review and meta-analysis evaluated the association between frailty and outcomes after PAD revascularization.

Methods

Methods: PubMed, Embase, and Cochrane Library were searched from inception to May 12, 2026. Studies assessing frailty in patients undergoing peripheral artery surgery (endovascular, open, or hybrid lower extremity revascularization) for PAD were included. Random-effects meta-analyses were performed using odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs). Prespecified subgroup analyses were conducted according to frailty assessment approach (Frailty Index-type vs. Non-Frailty Index tools) and procedural strategy.

Results

Nineteen studies comprising 1,638,543 patients were included. Because some studies enrolled mixed PAD populations, only patients undergoing lower extremity revascularization contributed to the pooled analyses. Frailty was associated with increased early mortality (OR 4.74; 95% CI 1.75-12.87), late mortality (HR 1.59; 95% CI 1.07-2.36), and major adverse cardiovascular events (OR 2.56; 95% CI 1.15-5.71), but not with major amputation, major adverse limb events, or postoperative complications. Subgroup analyses demonstrated no significant differences according to frailty assessment approach or procedural strategy.

Conclusion

Frailty is associated with substantially worse outcomes following lower extremity revascularization for PAD, particularly increased early and late mortality and major adverse cardiovascular events, consistently across different frailty assessment approaches. These findings support routine incorporation of frailty assessment into preoperative evaluation to improve risk stratification, shared decision-making, and perioperative optimization.