The impact of preoperative smoking cessation on outcomes of elective suprainguinal bypasses in patients with aortoiliac occlusive disease: A propensity-score matched analysis.

Abstract

Smoking cessation before elective surgery is generally recommended to reduce cardiovascular and respiratory risk as well as achieving favorable outcomes. This study aimed to evaluate the impact of preoperative smoking cessation on the outcomes of elective suprainguinal bypasses (SIB) for aortoiliac occlusive disease using data from the Vascular Quality Initiative. We retrospectively analyzed the Vascular Quality Initiative database (2009-2023) for elective SIBs for aortoiliac occlusive disease. Both claudication and chronic limb-threatening ischemia (CLTI) were included. A one-to-one propensity score matching (PSM) created two cohorts: active smokers (ASs) vs former smokers (FS). A FS was defined as quitting smoking ≥1 month before surgery. PSM was based on demographics, comorbidities, preoperative medications, prior procedures, indication for bypass, type of bypass, and concomitant procedures. Primary outcomes were 30-day, 1-year, and 3-year mortality. Secondary outcomes included postoperative complications, 1-year major amputation, reintervention, major adverse limb event, and combination of these events. One- and 3-year outcomes were adjusted for discharge medications and smoking status at follow-up. Before PSM, there were 6962 FS (41.8%) vs 9708 AS (58.2%) cases. FS patients were more likely to be older (66.7 years vs 61.4 years; P < .001), female (42.4% vs 40.3%; P = .007), have severe cardiovascular comorbidities, and undergo extra-anatomical bypass, whereas AS patients were more likely to have chronic obstructive pulmonary disease (39.2% vs 34.2%; P < .001) and present with CLTI (51.3% vs 46.6%; P < .001). After PSM, we created 4831 pairs of FS and AS cases. Active smoking was associated with an increased risk of respiratory complications (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.11-1.62; P = .002), but not with 30-day mortality, myocardial infarction, surgical site infection, or major amputation/reintervention. Additionally, AS had increased hazards for death at 1 year (adjusted hazard ratio [aHR], 1.76; 95% CI, 1.10-2.81; P = .018) and 3 years (aHR, 1.68; 95% CI, 1.26-2.28; P < .001). In a subanalysis of outcomes based on presentation, AS was associated with increased risk of respiratory complications in both claudication (OR, 1.35; 95% CI, 1.03-1.77; P = .029) and CLTI (OR, 1.34; 95% CI, 1.02-1.75; P = .032). However, in survival analysis, AS had an increased hazard of 3-year death only in patients with CLTI (aHR, 1.67; 95% CI, 1.19-2.36; P = .003). Active smoking at the time of elective SIB was associated with increased respiratory complications and worse long-term survival, particularly among patients with CLTI. These findings support prioritizing smoking cessation as part of perioperative risk optimization in patients undergoing suprainguinal revascularization. Further studies are needed to evaluate the impact of longer durations of preoperative cessation on postoperative outcomes.