Frequency and Intensity of Smoking, Duration of Smoking Cessation, and Risk of Early Postoperative Outcomes after High-risk Arterial Reconstructions

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Introduction: The relative influence of smoking and smoking duration/intensity in a co-morbid cohort is uncertain. We examined whether smoking status, duration of cessation, and smoking frequency/intensity significantly affected postoperative morbidity and mortality risk. Methods: We collected single institution, retrospective data from consecutive patients undergoing open operative intervention for carotid, aortoiliac, or infrainguinal aneurysmal or occlusive arterial disease. Smoking cessation duration was calculated as the time between smoking cessation and index surgery. The primary outcome was a composite of 30-day mortality and morbidity. Logistic and Cox regressions estimated associations between the primary outcome and smoking status with interaction terms between cessation duration and intensity (pack-years) for former smokers. Results: Between 2010 and 2019, 1,087 patients underwent 1,523 high-risk surgeries. The mean duration of cessation was 19.3 years (standard deviation [SD] = 16.2). Mean pack-year history was 45.2 pack-years (SD=33.7) among former smokers and 54.8 pack-years (SD=38.5) among current smokers (p < 0.001). Smoking status did not independently predict an increased risk of postoperative mortality or morbidity (Odds Ratio [OR]=0.97, p = 0.85). In the former smoker group, neither smoking cessation duration (OR=0.99, p = 0.23) nor pack-years (OR=1.00, p = 0.99) were statistically significant predictors of adverse events (interaction p = 0.08). Long-term survival probabilities were lower among current smokers (Hazard Ratio [HR] = 1.31, p = 0.002) with no significant effect from either pack-years or cessation duration. Conclusion: Among patients undergoing procedures that represent systemic disease, the adverse effects of continued smoking are better appreciated in long-term survival probability reduction that is observed regardless of smoking frequency or intensity.