title: Preoperative smoking is associated with early graft failure after infrainguinal bypass surgery.
abstract: OBJECTIVE
  Smoking has been implicated as the single most important risk factor for the development of peripheral arterial disease. Whereas previous studies have found poor long-term outcomes in smokers undergoing lower extremity bypass, there is a lack of consistent reports describing the effects of persistent tobacco abuse on early outcomes after infrainguinal bypass.
  
  
  METHODS
  The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2011 was queried for primary infrainguinal bypasses. A bivariate analysis was done to assess preoperative and intraoperative risk factors for the primary outcome of 30-day graft failure comparing active smokers with nonsmokers, defined as patients who did not smoke within the 12 months before surgery. Multivariable logistic regression was conducted to assess the independent association of active smoking with graft failure.
  
  
  RESULTS
  In 6614 (40.0%) active smokers and 9920 (60.0%) nonsmokers, 16,534 infrainguinal bypasses were performed. Active smokers were more likely to be younger, male, and of nonwhite race and to have a history of chronic obstructive pulmonary disease (P < .001, all). Nonsmokers were more likely to be functionally dependent and had significantly more comorbidities (ie, hypertension, diabetes, obesity, congestive heart failure, history of previous cardiac surgery or intervention, and dialysis; P < .001, all). The presence of critical limb ischemia was similar in both groups (53.1% of active smokers vs 53.5% of nonsmokers; P = .61). More nonsmokers received a tibial-level bypass than did active smokers (47.8% vs 33.9%; P < .001). There was a trend toward increased early graft failure in active smokers compared with nonsmokers (5.3% vs 4.7%; P = .08). With adjustment for other variables, especially bypass level and graft type, there was an independent association between active smoking and early graft failure (adjusted odds ratio, 1.21; 95% confidence interval, 1.02-1.43; P = .03).
  
  
  CONCLUSIONS
  Although nonsmokers were significantly older, had more comorbidities, and required more distal revascularization, active smokers still had an increased risk for development of early graft failure. These results stress the need for immediate smoking cessation before lower extremity bypass. Further research is warranted to determine an optimal period of abstinence among smokers with peripheral arterial disease to reduce their risk for early graft failure.
authors: Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
authors: Shalini
authors: S
authors: Selvarajah
authors: Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, Md.
authors: James H
authors: JH
authors: Black
authors: Department of Vascular Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md.
authors: Mahmoud B
authors: MB
authors: Malas
authors: Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, Md.
authors: Ying Wei
authors: YW
authors: Lum
authors: Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, Md.
authors: Brandon W
authors: BW
authors: Propper
authors: Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md; Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, Md. Electronic address: chrisabularrage@yahoo.com.
authors: Christopher J
authors: CJ
authors: Abularrage
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D016009:Chi-Square Distribution; D015897:Comorbidity; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000601:surgery*; D012307:Risk Factors; D012737:Sex Factors; D012907:Smoking / Q000009:adverse effects*; D016540:Smoking Cessation; D000074606:Smoking Prevention; D013997:Time Factors; D017211:Treatment Failure