1. In a large cohort of patients with intermittent claudication, smoking prior to open and endovascular revascularization was associated with increased post-procedural complications.
Evidence Rating Level: 2 (Good)
Treatment guidelines for intermittent claudication (IC) recommend optimal medical therapy, which includes smoking cessation, prior to considering revascularization. However, most patients are not medically optimized prior to revascularization. Therefore, this retrospective cohort study sought to determine the association between smoking and post-procedural complications following revascularization for IC. It made use of data from the Veterans Affairs Surgical Quality Improvement Program. There was a total of 14,350 cases of revascularization for IC included in the study (mean [SD] age = 65.7 [7.0] years; 14,090 [98.2%] male). 7,820 (54.5%) of patients were smoking within the year prior to the procedure, which was defined as the exposure. The study implemented propensity score matching in which 3,855 smokers were matched to 3,855 non-smokers with otherwise similar characteristics. The primary outcome was any post-procedural complication within 30 days. It was found that smokers had a higher risk of any 30 day post-procedural complication compared to non-smokers (484 [12.6%] vs 34 [8.9%]) with an absolute risk difference (ARD) of 3.68% (95% CI, 2.31-5.06; p<0.001). The increased risk in smokers was preserved across all subgroups of different types of procedures, including endovascular revascularization (ARD, 2.19%; 95% CI, 0.77-3.60; p=0.003), hybrid revascularization (ARD, 3.18%; 95% CI, 0.23-6.13; p =0 .04), and open revascularization (ARD, 5.18%; 95% CI, 2.78-7.58; p < 0.001). The secondary outcomes measured were 30 day post-procedural major and minor complications, complications by organ systems, and mortality. It was found that smokers had a higher risk of major (ARD, 1.56%; 95% CI, 0.51-2.60; p =0 .004), minor (ARD, 2.65%; 95% CI, 1.63-3.67; p<0 .001), wound (ARD, 1.84%; 95% CI, 0.75-2.93; p =0 .001), respiratory (ARD, 1.30%; 95% CI, 0.75-1.85; p<0 .001, and thrombotic complications (ARD, 0.67%; 95% CI, 0.10-1.24; p =0 .02) compared to non-smokers. Additionally, smoking was found to be associated with increased 30-day mortality (23 [0.6%] vs 2 [0.1%]; ARD, 0.54%; 95% CI, 0.29-0.80). Overall, this is a large and well-designed study that demonstrated increased risk of post-revascularization complications in patients who smoked within 1 year of the procedure.
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