Long-term Outcomes in the Smoking Claudicant After Elective Lower Extremity Bypass

Abstract

Smoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is in general surgery. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants. We queried the Vascular Quality Initiative VISION LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 25 clinical variables (age, gender, race, ethnicity, treatment setting, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass grafting, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from target lesion reintervention (FTR) and amputation-free survival (AFS). Propensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.70-1.24; P = .61), LS (HR, 1.08; 95% CI, 0.63-1.82; P = .80), FTR (HR, 0.95; 95% CI, 0.73-1.23; P = .69), or AFS (HR, 0.93; 95% CI, 0.71-1.2; P = .62) (Fig 1). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI, 0.94-1.97; P = .10) or FTR (HR, 1.02; 95% CI, 0.87-1.19; P = .85). However, we did find a significant increase in OS (HR, 1.37; 95% CI, 1.15-1.64; P < .001) and AFS (HR, 1.38; 95% CI, 1.18-1.62; P < .001) (Fig 2) in FS compared to CS. Claudicants represent a unique nonemergent vascular patient population who can require LEB. Our study found that former smokers have better overall survival and amputation free survival when compared to current smokers, while former smokers mimic never smokers at 5-year outcomes for OS, LS, FTR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before and after LEB and can even be considered a requirement prior to elective LEB procedures in claudicants.Fig 2Amputation-free survival (AFS) (5 years) for former smokers (FS) and current smokers (CS) after propensity score matching.View Large Image Figure ViewerDownload Hi-res image Download (PPT)