Chamseddine Hassan, Shepard Alexander, Constantinou Constantinos, Nypaver Timothy, Weaver Mitchell, Boules Tamer, Kavousi Yasaman, Onofrey Kevin, Peshkepija Andi, Halabi Mouhammad, Kabbani Loay
Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI.
MyMichigan Vascular Surgery, University of Michigan Health, Midland, MI.
J Vasc Surg. 2025 Mar;81(3):650-657. doi: 10.1016/j.jvs.2024.11.022. Epub 2024 Nov 26.
Smoking cessation has been suggested as having the potential to improve the outcomes of carotid endarterectomy (CEA) and mitigate the risk of long-term stroke in patients with asymptomatic carotid stenosis (ACS). This study aims to compare the perioperative and long-term outcomes of CEA in patients with ACS across different smoking status groups.
All patients receiving an elective CEA for ACS between 2013 and 2023 were identified in the Vascular Quality Initiative (VQI). Patients with an ipsilateral carotid stenosis <70% and those receiving a concomitant coronary artery bypass graft were excluded. Patients were then classified according to their smoking status: never smokers, former smokers (defined as those who have stopped smoking more than 30 days prior to their operation), and current smokers. Patient characteristics and outcomes were compared using the χ or Fischer exact test as appropriate for categorical variables and the analysis of variance or Kruskal-Wallis test as appropriate for continuous variables. Cox regression analysis was used to study the association between smoking status and the primary outcomes of long-term stroke and major adverse cardiac events (MACE) defined as the composite outcome of stroke, myocardial infarction, and/or mortality.
A total of 77,664 patients received a CEA for ACS, of which 19,416 patients (25%) were never smokers, 39,374 patients (51%) were former smokers, and 18,874 patients (24%) were current smokers. Patients in the three groups had similar rates of perioperative stroke (P = .79), myocardial infarction (P = .07), mortality (P = .23), and MACE (P = .17). At 18-month follow-up, former and never smokers had similar rates of stroke (former 0.9% vs never 0.8%; P = .92), with former smokers exhibiting a lower stroke risk than current smokers (former 0.9% vs current 1.5%; P = .001). At 18 months, former smokers had a significantly lower rate of MACE compared with current smokers (former 11.8% vs current 13.2%; P = .03), but a higher rate compared with never smokers (former 11.8% vs never 8.7%; P < .001). On multivariate Cox regression analysis, compared with current smokers, former smokers were independently associated with a lower risk of stroke (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.53-0.87; P = .002), mortality (HR, 0.79; 95% CI, 0.74-0.84; P < .001), and MACE (HR, 0.77; 95% CI, 0.70-0.83; P < .001). No difference in long-term stroke risk was observed between former and never smokers (HR, 1.06; 95% CI, 0.82-1.38; P = .65).
This study demonstrates that preoperative smoking cessation in patients with ACS significantly reduces the risk of stroke, mortality, and MACE following CEA compared with continued smoking, aligning their outcomes more closely with those of never smokers. Optimizing patients with ACS prior to surgery should include smoking cessation counseling. Vascular surgeons play a critical role in encouraging smoking cessation, as their guidance can significantly improve patient outcomes following CEA.
已有研究表明戒烟有可能改善颈动脉内膜切除术（CEA）的手术效果，并降低无症状性颈动脉狭窄（ACS）患者发生长期卒中的风险。本研究旨在比较不同吸烟状态组的ACS患者接受CEA后的围手术期和长期手术效果。
在血管质量倡议（VQI）中确定了2013年至2023年间所有因ACS接受择期CEA的患者。排除同侧颈动脉狭窄<70%的患者以及接受同期冠状动脉旁路移植术的患者。然后根据患者的吸烟状态进行分类：从不吸烟者、既往吸烟者（定义为在手术前30天以上戒烟者）和当前吸烟者。使用χ²检验或Fisher精确检验（适用于分类变量）以及方差分析或Kruskal-Wallis检验（适用于连续变量）比较患者特征和手术效果。采用Cox回归分析研究吸烟状态与长期卒中及主要不良心脏事件（MACE，定义为卒中、心肌梗死和/或死亡的复合结局）等主要手术效果之间的关联。
共有77664例患者因ACS接受了CEA，其中19416例患者（25%）从不吸烟，39374例患者（51%）既往吸烟，18874例患者（24%）当前吸烟。三组患者围手术期卒中（P = 0.79）、心肌梗死（P = 0.07）、死亡率（P = 0.23）和MACE（P = 0.17）的发生率相似。在18个月的随访中，既往吸烟者和从不吸烟者的卒中发生率相似（既往吸烟者为0.9%，从不吸烟者为0.8%；P = 0.92），既往吸烟者的卒中风险低于当前吸烟者（既往吸烟者为0. .9%，当前吸烟者为1.5%；P = 0.001）。在18个月时，既往吸烟者的MACE发生率显著低于当前吸烟者（既往吸烟者为11.8%，当前吸烟者为13.2%；P = 0.03），但高于从不吸烟者（既往吸烟者为11.8%，从不吸烟者为8.7%；P < 0.001）。多因素Cox回归分析显示，与当前吸烟者相比，既往吸烟者发生卒中的风险较低（风险比[HR]，0.68；95%置信区间[CI]，0.53 - 0.87；P = 0.002）、死亡率较低（HR，0.79；95% CI，0.74 - 0.84；P < 0.001）以及MACE发生率较低（HR，0.77；95% CI，0.70 - 0.83；P < 0.001）。既往吸烟者和从不吸烟者在长期卒中风险方面未观察到差异（HR，1.06；95% CI，0.82 - 1.38；P = 0.65）。
本研究表明，与继续吸烟相比，ACS患者术前戒烟可显著降低CEA术后的卒中、死亡率和MACE风险，使其手术效果更接近从不吸烟者。对ACS患者进行术前优化应包括戒烟咨询。血管外科医生在鼓励戒烟方面发挥着关键作用，因为他们的指导可显著改善CEA术后患者的手术效果。
