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Active Smoking Is Associated With Increased Odds Of Limb Loss Among Claudicants Undergoing Infrainguinal Bypass
Raghuveer Vallabhaneni1, Corey A Kalbaugh1, Mark A. Farber2, Britt H Tonnessen3, Thomas E. Brothers4, William A. Marston1, John W. Hallett, Jr.3
1University of North Carolina-Chapel Hill, Chapel Hill, NC;2Raghu Vallabhaneni, Chapel Hill, NC;3Roper-St. Francis Healthcare, Charleston, SC;4Medical University of South Carolina, Charleston, SC

INTRODUCTION:Smoking cessation is one of the primary methods of treating claudication. However, many patients receive revascularization for claudication while still smoking. We examined regional data from the Vascular Quality Initiative (VQI) database to evaluate the impact of smoking on outcomes of revascularization in claudicants in the VQI.
METHODS:With consent of the members of the Carolinas Vascular Quality Group (CVQG) of the VQI, all cases entered in the infrainguinal (INF) bypass, suprainguinal (SI) bypass, and peripheral vascular intervention (PVI) modules were reviewed from 2010-2012. Univariate analysis was used to identify demographic and comorbid differences between active and non-active smokers. Multivariable regression modeling was used to assess primary outcomes of: major adverse limb event (MALE), amputation free survival (AFS), limb loss (LL), and death.
RESULTS:We identified 730 active smokers and 636 non-active smokers undergoing revascularization for claudication. Mean follow-up was 247(214) days. Active smokers were younger and had more COPD, but less diabetes, CHF, HTN and statin use. Multivariable regression modeling showed no differences in overall outcomes of MALE, AFS and death between active and non-active smokers when all procedure modules were combined; active smokers were more likely, however, to suffer limb loss [3% vs. 11%; OR=2.3 (1.0, 5.4), p=0.05]. When we examined the modules separately, there were no differences in outcomes between active and non-active smokers in PVI (n=1252 limbs) or SI bypass (n=122). Compared to non-active smokers, active smokers with claudication who received INF bypass had a much higher odds of MALE [21% vs 11%; OR=2.8(1.1, 7.4), p=0.03] and limb loss [10% vs 1%; OR=21.0 (1.5, 292), p=0.02], but had no difference in death or AFS.
CONCLUSIONS:: Claudicants who undergo INF bypass while actively smoking have increased odds of MALE and limb loss when compared to non-active smokers in the CVQG. Odds ratios for limb loss and MALE are significantly higher than that of previously reported patients with claudication treated with medical management. Prior to performing INF bypass on claudicants, aggressive smoking cessation methods should be implemented.
Primary Outcomes of Claudicants Undergoing INF by Smoking Status
Non-smokers (n=91)Chi-square pAdjusted OR, p
MALE21%11%0.042.8 (1.1,7.4), p=0.03
Amputation-Free Survival12%12%0.911.2 (0.4,3.2), p=0.8
Death3 %11%0.030.3 (0.08,1.23), p=0.09
Limb-Loss10%1%0.00821.0 (1.5,292), p=0.02


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