(PC048) The impact of preoperative smoking cessation on outcomes of elective suprainguinal bypasses in patients with aortoiliac occlusive disease: A propensity-score matched analysis

Objectives: Smoking cessation prior to elective surgery is generally recommended to reduce cardiovascular and respiratory risk as well as achieving favorable outcomes. This study aims to evaluate the impact of preoperative smoking cessation on the outcomes of elective suprainguinal bypasses for aortoiliac occlusive disease (AIOD) using data from the Vascular Quality Initiative (VQI).

Methods: We retrospectively analyzed the VQI database (2009-2023) for elective suprainguinal bypasses for AIOD. Both claudication and chronic limb-threatening ischemia (CLTI) were included. A one-to-one propensity score matching (PSM) created two cohorts: active smokers (AS) vs. former smokers (FS). Former smoker was defined as quitting smoking ≥1 month prior to surgery. PSM was based on demographics, comorbidities, preoperative medications, prior procedures, indication and type of bypass, and concomitant procedures. Primary outcomes were 30-day, one- and three-years mortality. Secondary outcomes included postoperative complications, one-year major amputation, and reintervention. One- and three-years outcomes were adjusted for discharge medications and smoking status at follow-up.

Results: Before PSM, there were 6,962 (41.8%) FS vs. 9,708 (58.2%) AS cases. FS patients were more likely to be older (66.7 vs. 61.4; P<.001), female (42.4% vs. 40.3%; P=0.007), have severe cardiovascular comorbidities, and undergo extra-anatomical bypass, while AS patients were more likely to have COPD (39.2% vs. 34.2%; P< 0.001) and present with CLTI (51.3% vs. 46.6%; P<.001). After PSM, we created 4,831 pairs of FS and AS cases. Active smoking was associated with an increased risk of respiratory complications (OR=1.34, 95%CI=1.11-1.62; P=0.002) but not with 30-day mortality, MI, surgical site infection, or major amputation/reintervention (Table I). Additionally, AS had increased hazards for death at one year (aHR=1.76, 95%CI=1.10-2.81; P=0.018) and three years (aHR=1.68, 95%CI=1.26-2.28; P< 0.001) (Table II). In a sub-analysis of outcomes based on presentation, active smoking was associated with increased risk of respiratory complications in both claudication (OR=1.35, 95%CI=1.03-1.77; P=0.029) and CLTI (OR=1.34, 95%CI=1.02-1.75; P=0.032). However, in survival analysis, AS had an increased hazard of three-years death only in patients with CLTI (aHR=1.67, 95%CI=1.19-2.36; P=0.003).

Conclusions: Our study suggests that smoking cessation should be prioritized prior to suprainguinal procedures to enhance outcomes and improve long-term survival of the patients. Particularly in patients with claudication, where timing of revascularization is less critical compared to CLTI, optimal medical therapy and smoking cessation should be considered prior to revascularization to achieve favorable outcomes. Future research should explore the impact of longer preoperative smoking cessation periods to further validate our findings.