Smoking Status Predicts Mortality After Carotid Endarterectomy for Symptomatic Disease but Not After Carotid Stenting or Transcarotid Revascularization

Abstract

Objective: To assess the impact of smoking on mortality after interventions for symptomatic carotid stenosis.

Methods: The VQI database was queried from 2003-2021 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 TIA, 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 (OR 1.359, 95% CI: 1.11-1.67) and former smoking (OR 1.321, 95% CI: 1.12-1.56) were predictive of 1-year mortality following CEA.

Conclusions: 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.