The Effect of Smoking Status on Perioperative Morbidity and Mortality after Open and Endovascular Abdominal Aortic Aneurysm Repair

Background: This study quantifies the extent to which active tobacco smoking is deleterious toward outcomes following open and endovascular abdominal aortic aneurysm (AAA) repair. Methods: Open and endovascular AAA repairs between January 2003 and June 2020 in the Vascular Quality Initiative were queried. Rupture, symptomatic status, and lack of 90 day follow-up were exclusions. Patients were then placed into 1 of 6 groups: open AAA with active smoking (n = 3,788), open AAA with prior smoking (n = 4,614), open AAA never smokers (817), endovascular AAA active smokers (n = 14,173), endovascular AAA former smokers (n = 25,831), and endovascular AAA never smokers (n = 6,064). Comparison of baseline char-acteristics, comorbidities, and adverse outcomes across each of the 6 cohorts was performed with open AAA in active smokers serving as the reference. Subanalysis investigating open AAA repair in active smokers relative to open AAA in patients confirmed in Vascular Quality Initiative to have quit smoking between 30 and 90 days before surgery was performed. Smoking cessation for a minimum of 30 days before surgery was required to fall into the former smoker category.Results: In comparing open AAA in active smokers to open AAA in former and never smokers, the active smokers experienced significantly higher rates of pneumonia (P < 0.001). Combined additive morbidity and mortality was highest (54%) in active smokers (P < 0.001) relative to all cohorts other than open AAA former smokers (P = 0.21). Smoking status did not impact morbidity or mortality incidence across individuals undergoing endovascular aneurysm repair. Binary logistic regression for all AAA patients (open and endovascular combined) revealed those with any history of smoking to be more likely to experience 90 day mortality (adjusted odds ratio [OR] 2.5 [2.2-2.9], P < 0.001) relative to never smokers. Active smokers were similarly more likely to experience 90 day mortality than prior/never smokers combined (OR 1.23 [1.07-1.38], P < 0.001). Mortality within 90 days was significantly more likely (P < 0.001) with aging, female gender, larger aneurysms, preoperative history of congestive heart failure, chronic obstructive pulmonary disease, chronic renal insufficiency, peripheral artery disease, and body mass index less than 20 and more than 35 mg/kg2. Diabetes and coronary artery disease were also associated with 90 day mortality (P = 0.045 and 0.049, respectively). Quitting smoking between 30 and 90 days before open repair reduced combined additive morbidity and mortality relative to active smokers (OR 1.34, P = 0.038).Conclusions: Smoking cessation 30 days before open AAA repair reduces perioperative morbidity and mortality. Smoking status does not impact morbidity and mortality in patients undergoing endovascular AAA repair. When combining all patients (open and endovascular), higher rates of 90 day mortality are associated with any history of smoking, aging, female gender, and advanced pre-existing comorbidities on a multivariable analysis.