The Effect of Smoking Cessation on Outcomes of Thoracic Endovascular Aortic Repair

Smoking is known to be a strong predictive factor for deleterious outcomes after surgical procedures; however, there is limited research that has focused on the effect of smoking cessation on the outcomes of thoracic endovascular aortic repair (TEVAR). Using a multi-institutional database, we aimed to determine if smoking cessation was associated with improved outcomes following TEVAR.

Patients undergoing thoracic endovascular aortic repair in Vascular Quality Initiative from 2013 to 2023 were categorized into three groups: never smokers (NS), those who quit smoking (QS) >30 days prior, or current smokers (CS) who quit ≤30 days prior or never quit. Primary outcomes include perioperative death, stroke, myocardial infarction, and spinal cord ischemia. Secondary outcomes include cardiac and pulmonary complications, prolonged length of stay (≥2 days), and leg and bowel ischemia. A multivariate logistic regression analysis was conducted to control for confounding variables. A subanalysis was performed to determine the impact of smoking cessation by TEVAR indication: thoracic aortic aneurysm and type B aortic dissection. Long-term outcomes were analyzed using Kaplan-Meier and Cox regression models.

There were 1,435 (30.4%) patients in the NS group, 1,867 patients (39.6%) in the QS group, and 1,412 (30.0%) patients in the CS group. Patients in the QS group were older and had the highest rate of comorbidities including diabetes, myocardial infarction, and congestive heart failure. Multivariate analysis revealed that the CS group had no significant difference in odds of perioperative death (adjusted odds ratio (aOR) = 1.40; [95% confidence interval (CI): 0.86-2.25]; P = 0.2), stroke (aOR = 1.19; [95% CI: 0.71-1.99]; P = 0.5), myocardial infarction (aOR = 1.54; [95% CI: 0.74-3.17]; P = 0.2), and spinal cord ischemia (aOR = 1.52; [95% CI: 0.95-2.45]; P = 0.083) compared to QS. However, CS had increased odds of leg ischemia (aOR = 3.75; [95% CI: 1.79-8.25]; P < 0.001) and 1-year mortality (adjusted hazard ratio (aHR) = 1.34; [95% CI: 1.01-1.79] P = 0.042) compared to QS. When stratified by indication, thoracic aortic aneurysm CS compared to QS had higher rates of leg ischemia (aOR = 3.46; [95% CI: 1.28-10.1]; P = 0.017) and 3-year mortality (aHR = 1.44; [95% CI: 1.02-2.03]; P = 0.036). Type B aortic dissection CS had no significant difference in postoperative outcomes but showed increased odds of 1-year mortality (aHR = 2.51; [95% CI: 1.17-5.54]; P = 0.02) compared to QS.

CS had similar risk of death, stroke, myocardial infarction, and spinal cord ischemia when compared to QS, regardless of indication. However, there was a significantly increased risk of 1-year and 3-year mortality for CS which was not seen with QS when compared to NS. These results suggest surgery should not be delayed for smoking cessation; however, smoking cessation counseling may be important for improving long-term outcomes.