Preoperative Osteosarcopenia Predicts Long-term Mortality and Cardiovascular Events After Endovascular Aneurysm Repair

Objective: Osteosarcopenia, the coexistence of sarcopenia and osteopenia, has recently emerged as a novel pathological concept. This study aimed to investigate the clinical significance of preoperative osteosarcopenia as a predictor of long-term outcomes in patients undergoing endovascular aneurysm repair (EVAR). Methods: A total of 240 patients (mean age, 77.8 ± 7 years) were included. Sarcopenia and osteopenia were assessed using opportunistic preoperative computed tomography (CT) scans. Sarcopenia was defined by the skeletal muscle index at the L3 level, and osteopenia was defined by the mean CT attenuation of the L1 vertebral body. Osteosarcopenia was defined as the concurrent presence of both conditions. To identify independent predictors of all-cause mortality and major adverse cardiovascular events (MACEs), multivariable Cox proportional hazards regression models were employed, adjusting for clinically relevant prognostic factors. Results: Patients were categorized into 4 groups: normal (n = 78, 32.5%), sarcopenia alone (n = 69, 28.8%), osteopenia alone (n = 32, 13.3%), and osteosarcopenia (n = 61, 25.4%). During a median follow-up of 5.0 (2.8, 6.8) years, 65 patients died. The osteosarcopenia group exhibited the poorest prognosis, with a 5-year survival rate of 55.8% compared with 89.4% in the normal group ( P < .001). Multivariable analysis identified osteosarcopenia as a potent independent predictor of all-cause mortality (hazard ratio [HR], 3.09; 95% confidence interval [CI], 1.44-6.65; P = .004) and MACE (HR, 5.01; 95% CI, 1.58-15.91; P = .006). In contrast, sarcopenia or osteopenia alone did not show independent prognostic significance. No significant differences were observed in 30-day mortality among the groups. Conclusions: Preoperative osteosarcopenia is a powerful, independent predictor of long-term mortality and MACE following EVAR. Since this condition can be readily identified through routine CT screening, it should be integrated into surgical risk assessment to optimize patient selection and facilitate personalized perioperative care. Clinical Impact This multicenter study demonstrates that preoperative osteosarcopenia—the concurrent loss of muscle and bone—is a potent independent predictor of mortality and major adverse cardiovascular events after endovascular aneurysm repair, whereas neither condition alone holds prognostic significance. This finding is innovative as it identifies a synergistic frailty phenotype previously overlooked by single-tissue assessments. For clinicians, these results advocate for the integration of opportunistic CT screening into routine preoperative workflows. By utilizing existing imaging to identify osteosarcopenia, practitioners can refine risk stratification, optimize cardiovascular management, and implement intensified postoperative surveillance for this high-risk patient group.