SS04 - Long-Term Outcomes in the Smoking Claudicant After Elective Lower Extremity Bypass

Objectives: 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.

Methods: We queried the Vascular Quality Initiative VISION LEB database from 2003-2019. In this database we found 609 (10.0%) never smokers (NS), 3,388 (55.3%) former smokers (FS), and 2,123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches (PSM) without replacement on 25 clinical variables [age, gender, race, ethnicity, treatment setting, obesity, insurance, hypertension, diabetes, CAD, CHF, COPD, CKD, previous CABG, CEA, major amputation, inflow treatment, preop medications and treatment type], one of FS to NS and a second analysis of CS to FS . Primary outcomes included five-year overall survival (OS), limb salvage (LS), freedom from target lesion reintervention (FTR) and amputation free survival (AFS).

Results: PSM resulted in 497 well matched pairs of NS and FS. In this analysis we found no difference in terms of OS [HR = 0.93, 95% CI 0.70-1.24, p=0.61], LS [HR = 1.08, 95% CI 0.63-1.82, p=0.80], FTR [HR = 0.95, 95% CI 0.73-1.23, p=0.69], or AFS [HR = 0.93, 95% CI 0.71-1.2, p=0.62 (Figure 1)]. In the second analysis, we had 1,451 well matched pairs of CS and FS. There was no difference in LS [HR = 1.36, 95% CI 0.94-1.97, p=0.10] or FTR [HR = 1.02, 95% CI 0.87-1.19, p=0.85]. However, we did find a significant increase in OS [HR = 1.37, 95% CI 1.15-1.64, p < 0.001] and AFS [HR = 1.38, 95% CI 1.18-1.62, p< 0.001 (Figure 2)] in FS compared to CS.

Conclusions: Claudicants represent a unique non-emergent 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.