Smoking Status Predicts Mortality after Carotid Endarterectomy for Symptomatic Disease but Not after Carotid Stenting
Mark Basilious1, Izzet Akosman1, Nakia Sarad1
1Division of Vascular & Endovascular Surgery, Weill Cornell Medicine, New York, NY.
Insights
Smoking increases 1-year mortality after carotid endarterectomy (CEA), but not after stenting procedures. Both active and former smokers face higher risks, emphasizing the need for smoking cessation in patients with carotid artery disease.
Area of Science:
- Vascular Surgery
- Cardiovascular Research
- Public Health
Background:
- Symptomatic carotid stenosis poses a significant risk of stroke.
- Surgical interventions like carotid endarterectomy (CEA) and stenting (TFCAS, TCAR) are performed to reduce this risk.
- The impact of smoking status on outcomes after these interventions requires further clarification.
Purpose of the Study:
- To evaluate the association between smoking status and mortality following interventions for symptomatic carotid artery stenosis.
- To compare outcomes across different intervention types (CEA, TFCAS, TCAR) based on smoking history.
Main Methods:
- Analysis of the VQI database (2003-2021) for patients undergoing CEA, TFCAS, or TCAR for symptomatic carotid stenosis.
- Classification of patients into never, former, or active smokers.
- Propensity score matching to control for confounding factors.
- Assessment of 30-day and 1-year mortality, TIA, stroke, and complications.
Main Results:
- Active smoking was linked to significantly higher 1-year mortality after CEA compared to never smokers (5.43% vs. 3.78%) and former smokers (5.73% vs. 4.57%).
- No significant differences in mortality were observed based on smoking status after TFCAS or TCAR.
- Active and former smoking were independent predictors of 1-year mortality following CEA.
Conclusions:
- Both active and former smoking are associated with increased 1-year mortality after CEA for symptomatic carotid stenosis.
- Smoking status does not appear to influence mortality after transfemoral carotid stenting (TFCAS) or transcarotid artery revascularization (TCAR).
- Smoking cessation is crucial for patients with carotid artery disease undergoing CEA.
Objective:
To assess the impact of smoking on mortality after interventions for symptomatic carotid stenosis.
Methods:
The Vascular Quality Initiative database was reviewed from 2003 to 2021 to identify patients undergoing interventions for symptomatic carotid artery stenosis with carotid endarterectomy (CEA), transfemoral carotid stenting (TFCAS), or transcarotid artery revascularization (TCAR). Patients were grouped as never, former (quit ≥1 month prior), or active smokers (smoking within 1 month). Propensity matching adjusted for demographics, comorbidities, preoperative medications, and additional risk factors. Primary outcomes were 30-day and 1-year mortality; secondary outcomes included 30-day transient ischemic attack, stroke, and other complications. Multivariate logistic regression identified independent predictors of mortality.
Results:
We identified 27,693 patients who underwent carotid artery interventions for symptomatic stenosis (CEA = 18,867; TFCAS = 5,388; TCAR = 3,438). After propensity score matching, no significant differences persisted in preoperative demographics and risk factors. After CEA, active smokers exhibited similar rates of 30-day mortality (1.19% vs. 0.89%, P = 0.338), but significantly higher rates of 1-year mortality (5.43% vs. 3.78%, P = 0.005) compared to never smokers. Active smokers also had an increased rate of 1-year mortality compared to former smokers (5.73% vs. 4.57%, P = 0.012). Mortality did not differ by smoking status after TFCAS or TCAR. There was an increased rate of overall complications in former smokers over never smokers undergoing TCAR (8.27% vs. 5.19%, P = 0.041), otherwise no other significant differences were noted in any of the secondary outcomes. On multivariate logistic regression analysis, both active smoking (odds ratio 1.395, 95% confidence interval: 1.11-1.67) and former smoking (odds ratio 1.321, 95% confidence interval: 1.12-1.56) were predictive of 1-year mortality following CEA.
Conclusion:
Both active and former smoking are independently associated with increased 1-year mortality following CEA for symptomatic carotid artery stenosis, but not after TFCAS or TCAR. Active smoking was associated with higher 1-year mortality than former smoking, highlighting the importance of smoking cessation in patients with carotid disease.
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