Smoking and the patency of lower extremity bypass grafts: a meta-analysis.
OBJECTIVE
Smoking is the major risk factor associated with the development and progression of peripheral arterial disease (PAD). To establish the best estimate of the effect of smoking, smoking cessation, and the dose-response relationship on the patency of lower extremity bypass grafts, we performed a systematic review.


METHODS
A search of medical articles and reviews relating to the influence of smoking on the patency of arterial reconstructive grafts in patients with PAD was made. Studies considered for inclusion were those that evaluated the influence of smoking on the primary, secondary, or cumulative patency rates of arterial reconstructive surgery in the lower extremities in patients with PAD. Primary data were used to calculate summary estimates with standard meta-analysis techniques.


RESULTS
The 29 eligible studies included 4 randomized clinical trials, 12 prospective studies, and 13 retrospective studies. The effect of smoking on graft patency in the randomized clinical trials and other prospective studies had a 3.09-fold (2.34 to 4.08; P < .00001) increase in graft failure. A comparison of patency rates among all studies that used autogenous or polyester grafts showed no difference. A clear dose-response relationship was present, with a decreased patency in heavy smokers compared with moderate smokers. Smoking cessation restores patency rates toward the never smokers group.


CONCLUSIONS
Continued smoking after lower limb bypass surgery results in a threefold increased risk of graft failure. Smoking cessation, even if instigated after the operation, restored graft patency towards the patency of never smokers. These results indicate that adequate smoking cessation strategies in patients eligible for lower limb bypass surgery are of utmost importance.
Willigendael
Edith M
EM
Division of Vascular Surgery, Department of Surgery, Atrium Medical Center, Netherlands.
Teijink
Joep A W
JA
Bartelink
Marie-Louise
ML
Peters
Ron J G
RJ
Büller
Harry R
HR
Prins
Martin H
MH
D019917:Blood Vessel Prosthesis Implantation; D006801:Humans; D007866:Leg / Q000098:blood supply; D016491:Peripheral Vascular Diseases / Q000601:surgery*; D011138:Polytetrafluoroethylene; D012307:Risk Factors; D012501:Saphenous Vein / Q000637:transplantation; D012907:Smoking / Q000503:physiopathology*; D016540:Smoking Cessation; D014471:Umbilical Veins / Q000637:transplantation; D014654:Vascular Patency / Q000502:physiology*; D014656:Vascular Surgical Procedures
D011138:Polytetrafluoroethylene