Revascularization of smokers with claudication is not predicted to limit quality of life despite a higher risk of late failure.
OBJECTIVE
Tobacco smoking after lower extremity revascularization for claudication has repeatedly been shown to increase the risk of adverse events, such that many vascular specialists consider that refusal to abstain from smoking constitutes a major contraindication to open surgical bypass or endovascular intervention.


METHODS
A Markov decision analysis (DA) model was used to compare the options of direct revascularization vs medical therapy only in smokers with claudication. The primary outcome was calculated quality of life (cQoL), determined for each patient at follow-up based on the outcomes of the treatment received. Markov DA software was used to predict the QoL for each treatment option preoperatively based on smoking status.


RESULTS
Among patients referred during a recent 64-month period with vasculogenic claudication, 94 were actively smoking compared with 217 who were not. The DA model predicted that if the patients who smoked were to discontinue smoking, the best therapy would be bypass surgery for 77% and endovascular intervention for 17%. However, despite at least doubling the risks with intervention in the patients who continue to smoke, the DA model still predicted that 78% and 9% would fare better with open surgical or endovascular intervention, respectively. Among actively smoking patients, open surgical (3%) or endovascular (4%) therapies were initially performed in few patients, whereas 93% were offered only medical therapy. Among initial nonsmokers, revascularization was performed by open (27%) or endovascular (42%) means. At 3 years, the median (interquartile range [IQR]) cQoL was lower in initial smokers than in nonsmokers (0.73 [IQR, 0.73-0.77] vs 0.82 [IQR, 0.75-0.86]; P < .0001), primarily because of a lack of revascularization for smokers. Among initial smokers who did undergo revascularization initially, because of progression of symptoms, or after smoking cessation, cQoL was similar to initial nonsmokers (0.77 [IQR, 0.73-0.84] vs 0.73 [IQR, 0.73-0.73]; P = .37). Although 26% of initial smokers had stopped by the time of their last follow-up, 10% of initially nonsmoking patients were smoking at follow-up. However, among all patients undergoing intervention, the cQoL of patients smoking at the time of last their follow-up was similar to nonsmokers (0.82 [IQR, 0.82-0.86] vs 0.83 [IQR, 0.73-0.86]; P = .99).


CONCLUSIONS
Patients with claudication who smoke may be denied the symptom improvement associated with revascularization, yet recidivism for smoking also occurs among patients who have stopped smoking in order to receive revascularization. The strategy not to directly revascularize patients with claudication who continue to smoke does not appear to maximize patient midterm QoL.
Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC.
Joshua D
JD
Mixson
Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Surgical Service, Department of Veterans Affairs Medical Center, Charleston, SC. Electronic address: brothete@musc.edu.
Thomas E
TE
Brothers
D000368:Aged; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D003661:Decision Support Techniques; D057510:Endovascular Procedures / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000175:diagnosis / Q000209:etiology / Q000523:psychology / Q000628:therapy*; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000209:etiology / Q000523:psychology / Q000628:therapy*; D011788:Quality of Life; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects*; D016540:Smoking Cessation; D000074606:Smoking Prevention; D013997:Time Factors; D017211:Treatment Failure; D014656:Vascular Surgical Procedures / Q000009:adverse effects*
D002317:Cardiovascular Agents