Elective Peripheral Vascular Intervention in the Smoking Claudicant

Emphasis on tobacco cessation given the urgent and emergent nature of vascular surgery is less prevalent than standard elective case such as hernia repairs, cosmetic surgery, and bariatric procedures. The goal of this study is to determine the effect of active smoking on individuals undergoing peripheral vascular interventions (PVI). Our goal is to determine if a greater emphasis on education should be placed on smoking cessation in nonurgent cases scheduled through clinic visits and not the emergency department. 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 and 2019 were included in our study. Our final sample consisted of a total of 18,726 patients: 3617 (19.3%) nonsmokers (NS), 9975 (53.3%) former smokers (FS), and 5134 (27.4%) current smokers (CS). We performed propensity score matching on 29 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, prior bypass or PVI, preoperative medications and treatment type) between NS to FS and FS to CS. Outcomes were long-term (5-year) overall survival (OS), limb salvage, freedom from target lesion reintervention (FTR), and amputation-free survival (AFS). Propensity score matches resulted with 3160 well-matched pairs of NS and FS and 3750 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 = .43), FTR (HR, 0.96; 95% CI, 0.89-1.04; P = .34), or AFS (HR, 0.90; 95% CI, 0.79-1.03; P = .12). However, when compared to CS, we found FS to have a higher OS (HR, 1.18; 95% CI, 1.04-1.33; P = .01), less FTR (HR, 0.89; 95% CI, 0.83-0.96; P = .002), and greater AFS (HR, 1.16; 95% CI, 1.03-1.31; P = .013) (Figure). 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, CS have lower OS and AFS 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 owing to the perceived 5-year benefit.