Smoking cessation duration is associated with the risk of amputation after revascularization for chronic limb-threatening ischemia.

Abstract

Background: Although smoking cessation has been shown to improve outcomes after lower extremity revascularization (LER), the impact of cessation duration has not been well-defined. This study investigates the impact of two cessation durations on LER outcomes in patients with chronic limb-threatening ischemia (CLTI).

Methods: The Peripheral Vascular Intervention, Infrainguinal Bypass, and Suprainguinal Bypass modules of the Vascular Quality Initiative were used to identify patients whose first recorded LER occurred between 2016 and 2024 for CLTI. Former smokers (FS) were divided into two groups based on the duration of smoking cessation. Recent FS had quit between 1 and 9 months before LER and 1-year FS had quite between 9 and 21 months to coincide with the standard follow-up period in the Vascular Quality Initiative. FS who quit more than 21 months before surgery were excluded. Two separate propensity score matches based on preoperative variables were performed at a three-to-one ratio, one of current smokers (CS) to recent FS and the other of CS to 1-year FS. Perioperative outcomes were compared along with Kaplan-Meier analysis for 1-year outcomes.

Results: There were 42,896 patients (84.7%) who were CS within 1 month of surgery, 4875 (11.4%) recent FS, and 2885 (5.7%) 1-year FS. Both groups of FS were significantly more likely to be older and have more cardiovascular comorbidities and prior revascularization procedures compared with CS. After matching, baseline characteristics were not different. There were no significant differences in perioperative complications between CS and recent FS or 1-year FS. Long-term outcomes were not different between CS and recent FS. However, patients in the 1-year FS group had significantly fewer major amputations compared with CS with no difference in thrombosis, reintervention, or mortality rates. On regression analysis, former smoking between 9 and 21 months was independently associated with lower major amputation compared with current smoking (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.58-0.90). Factors associated with higher major amputation included male sex (HR, 1.23; 95% CI, 1.02-1.48), Black race (HR, 1.52; 95% CI, 1.25-1.86), diabetes (HR, 1.59; 95% CI, 1.28-1.97), and end-stage renal disease (HR, 2.08; 95% CI, 1.61-2.70).

Conclusions: In this study, FS and CS had no difference in perioperative outcomes after LER for CLTI. Smoking cessation for a period of 9 to 21 months before LER, but not less than 9 months, was independently associated with decreased long-term major amputation compared with current smoking. Patients undergoing LER for CLTI may need to sustain smoking cessation for 2 years to begin experiencing measurable benefit with respect to limb salvage.