VESS11 - Smoking Cessation Duration to decrease the risk of amputation after Revascularization for Chronic Limb-Threatening Ischemia

Objectives: The SVS launched the CAN-DO campaign in 2023, promoting smoking cessation as a national focus for quality improvement. Although smoking cessation has been shown to improve outcomes after lower extremity revascularization (LER) the necessary duration for benefit has not been defined. This study investigates the impact of 1-year preoperative smoking cessation on LER outcomes in patients with chronic limb-threatening ischemia (CLTI).

Methods: The Peripheral Vascular Intervention (PVI), Infrainguinal Bypass (INFRA) and Suprainguinal Bypass (SUPRA) modules of the Vascular Quality Initiative (VQI) were utilized to identify patients’ index LER. Patients whose first LER within the VQI occurred between 2016-2024 for CLTI were included. Patients smoking within 30 days of surgery (current smokers), were compared with those who quit smoking between 9 and 21 months prior to surgery (former smokers). This 1-year cessation window, aligned with the VQI definition of 1-year outcomes, was selected to isolate the impact of 1-year cessation without including patients with more extensive cessation durations. Characteristics between current and former smokers were compared. Propensity matching was performed at a 3:1 ratio to control for preoperative differences, followed by evaluation of long-term outcomes.

Results: A total of 45,781 patients were included and 6.3% (N=2,885) had quit smoking in the 9-21 month period prior to LER. Former smokers were more likely to be younger, female, non-white, and less likely to have independent ambulation. Former smokers had significantly higher rates of most comorbidities but were more likely to be on best medical therapy. There was no difference between the 2 groups in perioperative amputation or other comorbidities however former smokers had significantly higher perioperative mortality. (Table I) Propensity matching resulted in a cohort 11,193 patients (25%, N=2,800 former smokers) with no significant difference in baseline characteristics. After matching, there was no significant difference between the 2 groups in perioperative morbidity or mortality. After a mean follow up of 377 days, current smokers experienced a significantly higher major amputation (13% vs 9.7%, P=0.001), with no difference in reintervention or mortality. Kaplan-Meier analysis was consistent (Fig 1). Regression analysis revealed former smoking status was associated with lower amputation compared to current smoking (HR=0.72[0.58-0.90]).

Conclusions: Smoking cessation within 9–21 months prior to LER significantly reduces long-term major amputation risk in patients with CLTI. Investigating other cessation durations can further define what time of frame of tobacco abstinence is required to lower adverse event risk, providing patients with a communicable cessation goal to improve their revascularization outcomes.