(IP219) Preoperative smoking cessation impacts presentation and long-term neurologic outcomes of carotid endarterectomy

Objectives: Smoking cigarettes in patients with carotid disease increases the risk of perioperative mortality following carotid endarterectomy (CEA). However, the impact of smoking cessation before CEA on outcomes remains unclear. This study aims to evaluate the effect of preoperative smoking cessation on long-term outcomes after CEA in the Vascular Quality Initiative (VQI), with the hypothesis being that smoking cessation improves long-term outcomes after CEA.

Methods: Patients from 2012-2023 in the VQI who smoked within 30 days of their CEA were referred to as “smokers” in this abstract and patients who quit smoking 9-21 months prior to their CEA were referred to as “former smokers”. A duration of smoking cessation of 9-21 months prior to surgery was chosen because it aligns with the long-term follow up window in the VQI and allows for assessment of the effect of a specific duration trackable within the confines of the registry. Patients with missing long-term follow up as well as patients who changed smoking status on long-term follow up were excluded. Long-term outcomes were compared between smokers and former smokers using bivariate and Kaplan-Meier analysis. Cox regression was used to assess the effect of smoking status on outcomes.

Results: There were 20,390 smokers and 2,368 former smokers (mean duration of preoperative smoking cessation=14.4 months) identified. Former smokers were older and more likely to be Hispanic and male. Former smokers were significantly more likely to have hypertension, diabetes, cardiovascular disease, and renal disease while smokers were more likely to have chronic obstructive pulmonary disease (COPD). Smokers were more likely to present with symptoms and more likely to require urgent surgery. After a mean follow-up of 415 days, smokers had higher mortality and ipsilateral transient ischemic attack (TIA) or stroke despite having significantly less comorbidities (Table). Kaplan-Meier analysis revealed ipsilateral TIA or stroke was significantly greater in smokers compared to former smokers (Figure). On regression analysis, Female sex (HR=1.46[1.12, 1.90]), younger age (HR=0.98[0.97, 0.99]), diabetes (HR=1.64[1.24, 2.17]), presentation with stroke (HR=3.45[2.53, 4.69]) and TIA (HR=1.77[1.22, 2.57]) were associated with long-term TIA or stroke. Former smoking was associated with lower TIA or stroke (HR=0.67, [0.4, 1.12]) but association did not reach statistical significance.

Conclusions: Smokers undergoing CEA are more likely to present with symptoms. Smoking cessation improves the long-term outcomes of CEA, but neurological outcomes seem to be more driven by younger age, diabetes, female sex, and presence of neurological symptoms on presentation.