Claudicants Who Smoke Have Higher Rates of Major Adverse Limb Events After Infrainguinal Bypass Than Former Smokers
Corey A. Kalbaugh, PhD1, Thomas E. Brothers, MD2, Mark A. Farber, MD1, Adam W. Beck, MD3, John Hallet, MD2, William A. Marston, MD1, Raghuveer Vallabhaneni, MD4.
1University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, 2Medical University of South Carolina, Charleston, SC, USA, 3University of Alabama Birmingham, Birmingham, AL, USA, 4MedStar Union Memorial Hospital, Baltimore, MD, USA.
OBJECTIVE Revascularization of claudicants, particularly for those who are actively smoking, remains a controversial topic. The purpose of this study was to evaluate the impact of smoking on outcomes following infrainguinal bypass for claudication.
METHODS: We used data from the national Vascular Quality Initiative (VQI) to assess the impact of smoking on outcomes following infrainguinal bypass for claudication. Patients were excluded based on presentation other than claudication, race other than white or black, less than one year of follow-up, those with missing smoking data, and limbs with previous interventions. Demographic and comorbid differences were assessed using chi square testing with p<0.05 indicating statistical significance. Significant variables were entered into a logistic regression model to calculate odds ratios (OR) and 95% confidence intervals (CI) by smoking status for outcomes of major adverse limb event (MALE), amputation-free survival, limb loss and death. Results were also stratified by conduit (vein vs. prosthetic) and location (above- vs. below-knee).
RESULTS: We identified 3,240 infrainguinal bypasses among 3,017 patients with claudication to be included in study. Of these 3,017 patients, there were 1,359 current smokers, 1,327 former smokers, and 331 never smokers. Compared to former smokers, current smokers were younger at the time of bypass and had fewer comorbid conditions. Smokers were more likely than former smokers to experience MALE (OR: 1.34; 95% CI: 1.09, 1.66, p=0.01). Limb loss was higher among those with prosthetic bypasses as compared to those with vein bypasses (3.2% vs. 1.8%, p=0.01). The highest rates of limb loss occurred among active and former smokers with below knee prosthetic bypasses (11.8% and 8.3%, respectively). Other outcomes measured were not different by smoking status.
CONCLUSIONS Claudicants who undergo infrainguinal bypass while actively smoking have an increased risk of MALE when compared to former smokers in this sample of the VQI database. Limb loss is particularly high among claudicants who receive a prosthetic bypass to a below-knee artery, especially among smokers. Smoking cessation and medical management for claudicants requiring below knee prosthetic bypasses should be considered.
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