Objectives

Emphasis on tobacco cessation given the urgent and emergent nature of vascular surgery is less prevalent than standard elective cases such as hernia repairs, cosmetic surgery, and bariatric procedures. The goal of this study is to determine the effect of active smoking on claudicating individuals undergoing peripheral vascular interventions (PVI). Our goal is to determine if a greater emphasis on education should be placed on smoking cessation in non-urgent cases scheduled through clinic visits and not the Emergency Department.

Methods

This study was performed using the multi-institution de-identified Vascular Quality Initiative-Medicare-Linked database (VISION). Claudicants who underwent PVI for peripheral arterial occlusive disease between 2004-2019 were included in our study. Our final sample consisted of a total of 18,726 patients: 3,617 (19.3%) nonsmokers (NS), 9,975 (53.3%) former smokers (FS) and 5,134 (27.4%) current smokers (CS). We performed propensity score matching (PSM) on 29 variables [age, gender, race, ethnicity, treatment setting (outpatient or inpatient), obesity, insurance, hypertension, diabetes, CAD, CHF, COPD, CKD, previous CABG, CEA, major amputation, inflow treatment, prior bypass or PVI, preop medications, level of treatment, concomitant endarterectomy, and treatment type (atherectomy, angioplasty, stent)] between NS versus FS and FS versus CS. Outcomes were long-term (five-year) overall survival (OS), limb salvage (LS), freedom from reintervention (FR) and amputation free survival (AFS).

Results

PSM resulted with 3,160 well matched pairs of NS and FS and 3,750 well matched pairs of FS and CS. There was no difference between FS and NS in terms of OS [HR = 0.94, 95% CI 0.82-1.09, p=0.43], FR [HR = 0.96, 95% CI 0.89-1.04, p=0.35], or AFS [HR = 0.90, 95% CI 0.79-1.03, p=0.12]. However, when compared to CS, we found FS to have a higher OS [HR = 1.18, 95% CI 1.04-1.33, p =0.01], less FR [HR = 0.89, 95% CI 0.83-0.96, p=0.003] and greater AFS [HR = 1.16, 95% CI 1.03-1.31, p=0.01].

Conclusion

This multi-institutional Medicare-linked study looking at elective PVI cases in PAD patients presenting with claudication found that former smokers have similar 5-year outcomes in comparison to non-smokers in terms of OS, FTR and AFS. Additionally, current smokers have lower overall survival and amputation free survival when compared to former-smokers. Overall, this suggests that smoking claudicants should be highly encouraged and referred to structured smoking cessation programs or even required to stop smoking prior to elective PVI due to the perceived 5-year benefit.