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The effect of continued cigarette smoking on the patency of synthetic vascular grafts in Leriche syndrome
The effect of continued cigarette smoking on the patency of synthetic vascular grafts in Leriche syndrome The effects of continued smoking were studied in 187 consecutive patients who underwent aorto-i1iac or aorto-jemoral grafting because of Leriche disease and who left the hospital with well-functioning grafts. The patients were divided into the following groups: (1) never smoked, (2) stopped smoking after the operation, (3) continued to smoke less than a pack a day, and (4) continued to smoke more than a pack a day. The patency of the grafts was evaluated at regular intervals during a follow-up period ranging from 6 months to 10 years. A significant difference in the patency in the favor of the nonsmokers was found, with the "more than one pack a day" group having more than triple the occlusion rate of the nonsmokers, both absolutely and in month-patency time. We recommend that the surgeon make a most sincere effort to induce patients undergoing vascular operations for occlusive vascular disease to give up smoking. Failure to promise to stop the smoking habit should be regarded as a relatively strong contraindication for surgery in patients not directly threatened with loss of an extremity.
Francis Robicsek, M.D., Harry K. Daugherty, M.D., Donald C. Mullen, M.D., Thomas N. Masters, Ph.D., Dundar Narbay, M.D., and Paul W. Sanger, M.D., t Charlotte, N. C.
For thy sake, Tobacco, I would do anything, but die. Charles Lamb, 1803
The harmful effects of nicotine abuse upon the cardiovascular system in general- 2, 4, 6-8, 11-18, 20, 22, 24, 25, 27,28, 30, 31, 33, 36, 37, 39 and on the arterial circulation of the lower extremities in particular- 5, 9, 10, 19, 21, 23, 26, 29, 32, 35, 37, 38, 40, 41, 42 have been proved by several independent studies. It is now generally recognized that cigarette smoking is a significant factor in the development and progression of occlusive arteriosclerosis in both coronary and the peripheral circulation. In the surgical management of arterial From the Department of Thoracic and Cardiovascular Surgery and the Heineman Medical Research Laboratories, Charlotte Memorial Hospital, Charlotte, N. C. Received for publication Feb. 3, 1975. tOr. Sanger is deceased.
occlusive disease of the lower abdominal aorta and iliac arteries (Leriche syndrome), we were particularly impressed by two everrecurring observations: ( I ) the disproportionally high percentage of smokers among our patients whose disease was severe enough to warrant surgery and (2) the poor prognosis of those who continued to smoke after the otherwise successful operation. In the following report, we attempt to convert this general observation into a more objective statistical study with the intent of drawing some practical conclusions.
Clinical material and methods During the past decade, a total of 367 consecutive patients have undergone different types of arterial grafting procedures on our service for lower limb ischemia. From the technical viewpoint, these patients
107
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Thoracic and Cardiovascular Surgery
were divided into two major groups: ( 1) patients in whom the graft extended from the abdominal aorta to the iliac or femoral arteries and (2) patients in whom femoropopliteal or femoro-tibial grafting was done. We have found that, in the first group (220 patients), our indication for surgery, the operative technique, and the graft material changed very little during the past 15 years. Therefore, the patients represented a fairly uniform study material. By comparison, in the second group (147 patients), all three of these factors changed considerably during this time period. The statistical study of the latter group would have necessitated a further breakdown of patients into subgroups so small that their evaluation would have been meaningless. Our general clinical impression on the effects of smoking on the patency of arterial bypass grafts in the two groups was about the same. However, for the reasons mentioned, we decided to limit our observations to patients belonging to the first group, in whom the principal occlusive site was the lower aorta and the iliac system (Leriche syndrome). All the patients included in the study suffered from circulatory deficit of the lower extremities, their symptoms varying from intermittent claudication to frank gangrene of the toes. Before the operation, angiographic studies were performed in all patients. The surgical procedure consisted of a midline laparotomy, exploration of the abdominal aorta, the iliac artery, and if it appeared necessary, the femoral vessels. The narrowed or occluded vascular segment was replaced in some and bypassed in others with a bifurcated vascular prosthesis made of woven Dacron. The graft was anastomosed to the aorta proximally and to the iliac or common femoral vessels distally. In a number of cases, the extent of the disease also necessitated an endarterectomy and/or arterioplasty of the vascular segment lying immediately proximal or distal to the anastomotic connections. Of 220 patients, 207 survived the opera-
tion and left the hospital alive. They were followed as outpatients at regular intervals, at which time they were questioned about their smoking habits and were examined clinically. Absence of one or both femoral pulses within 3 months after the operation was probably due to either misjudging the available vascular bed for graft-flow runoff, to faulty operative technique, or both. This criterion also eliminated a small, but nonetheless significant, number of patients (11) from further study. Thirteen patients who smoked a pipe or cigar or who chewed or snuffed tobacco were also excluded from the study, because of the statistically insignificant size of this group. Results
Of the 183 patients, 159 were followed either to the date of the study or until the disappearance of their femoral pulse, which implied occlusion of the graft. Sixteen patients were lost to follow-up, and 11 patients died of causes unrelated to the operation. The time period between the operation and their last office visit, when the patency of the graft was still confirmed, was also included in this study. Group I was composed of 10 patients, 4 of whom were women, who did not smoke either before or after the operation. Four of them had aorto-iliac and 6 had aortofemoral grafts (or an aorto-iliac graft on one side and an aorto-femoral graft on the other). The average age of the patients was 53 years. Four had a history of diabetes mellitus. During this period of 502 follow-up months (for the whole group), none of the grafts became occluded. Group II included 95 patients, 15 of whom were women, who were cigarette smokers before surgery but quit their habit after the operation. Fourteen were treated by aorto-iliac grafting and 81 aorto-femoral grafting. The average age was 56 years. Nineteen of these patients had diabetes. Within a period of 4,489 follow-up months, there were 10 graft occlusions or an occlusion rate of 1/448 months.
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Effect of cigarette smoking in vascular disease
July, 1975
Group III comprised 52 patients, including 10 women. They were cigarette smokers before surgery and continued to smoke after the operation, but less than a pack a day. Twenty-six had aorto-iliac and 26 had aorto-femoral grafts. The average age of the patients was 5 I, and there were 7 who had diabetes. During a period of 2,757 follow-up months, 8 grafts became occluded, for an occlusion rate of 1/342 months. Group IV was formed by 26 patients who remained heavy smokers after the operation and consumed more than a pack of cigarettes a day. Eight underwent aorto-iliac grafting and the other 18 underwent aortofemoral grafting. Of the 7 women and 19 men included in this group, 7 had diabetes. The average age of the group was 56 years. This group was observed for a total of 1,093 follow-up months, during which 8 graft occlusions occurred, for an occlusion rate of 1/137 follow-up months. Group V represented the 105 patients already described in Groups I and II, i.e., all the individuals who did not smoke after surgery. There were 18 aorto-iliac and 87 aorto-femoral grafts. Nineteen of these patients were women and 88 men, with an average age of 55 years. Twenty-three of them had a history of diabetes. The combined follow-up time for this group was 4,991 months, during which 10 graft occlusions occurred. This represents an occlusion rate of 1/499 follow-up months. Group VI was composed of 78 patients described in Groups III and IV, 17 of them women. There were 34 aorto-iliac and 44 aorto-femoral grafts. The average age of the total group was 54 years, and 14 patients had diabetes. During the total follow-up period of 3,850 months, there were 16 graft occlusions or an occlusion rate of 1/240 follow-up months. A graphic display of the data of the six groups is given in Figs. 1 to 3. The possible result of a patient's decision to continue smoking is shown in Fig. 4.
I
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I i · 0l-v 0 1e 8 0 0 P Fig. 1. Graph showing the state of patency of bifurcated Dacron woven grafts. The Roman numerals represent the following groups: I, those who did not smoke before or after surgery; II, those who quit smoking after surgery; Ill, those who continued to smoke less than one pack a day after surgery; IV, those who continued to smoke more than one pack a day after surgery; V, all nonsmokers after surgery; VI, all smokers after surgery. The vertical Column A's are aortoiliac grafts. The vertical Column B's are aortofemoral grafts. The white circles represent open grafts, and the black circles represent occluded grafts. The vertical calibration represents years of observation and/or the time at graft occlusion.
Comments The pathological processes of occlusive arteriosclerosis occurring in the heart, head, and peripheral vessels appear to be identical. Cigarette smoking has been shown to be one of the most important factors in coronary heart disease and stroke;'- 4, 6-8, 12-10, 18, .20, 22, '" and it would be most strange if this were not also true for disease of the peripheral arteries. .In 1962, Eastcott" wrote: "I now never diagnose atheroma as a cause of ischemia (of the legs) in a male non-smoker." Although this may be
The Journol of
1 10
Robicsek et af.
Thoracic and Cardiovascular Surgery
%
Occlosion
Rale
40
30
20
10
Group
I
:IT
ill
N:
Fig. 2. Occlusion rate of bifurcated Dacron woven grafts. For explanation of groups, see Fig. 1.
II Ocelo. lo. hte
Fig. 3. Occlusion rate per observation month in the different groups . For explanation of groups see Fig . 1.
somewhat overstated, it is certain that leg ischemia caused by arteriosclerosis is very rare in the nonsmoker. Lord. t" reviewing the charts of 100 consecutive patients operated upon for peripheral arterial disease of the aorto-iliac tree or of the femoro-popliteal arteries , found only 2 nonsmokers among them. Kannel and Shurtleff;" interpreting the data obtained by the Framingham study based on 16 years of cardiovascular surveillance of more than 5,000 subjects, also found a "striking relationship"
Fig. 4. Is it worth it?
between the habit of cigarette smoking and the rate of occurrence of intermittent claudication. Similar observations have been reported by Weinroth and Herzstein," by Juergens, Barker and Hines, III and by others. Our study , which was done on 183 consecutive patients operated upon for Leriche syndrome, not only has confirmed these observations but has made another point: It has proved that if the victim of tobacco addiction continues to smoke after an otherwise successful grafting procedure, the risk of graft occlusion at a later period is much higher than in those who quit smoking cigarettes. There is ample evidence that the nicotine absorbed from inhaled cigarette smoke has effects on the circulation. Mustard and Murphy'" have shown that cigarette smoking shortens platelet survival and accelerates blood coagulation. Kershbaum and Beller" have demonstrated that cigarette smoking causes a rapid and consistent rise in serum free fatty acids and increases the excretion of urinary catecholamines. Westfall and Watts '" found that the rate of excretion of both epinephrine and catecholamines is
Volume 70 Number 1
Effect of cigarette smoking in vascular disease
I I I
July, 1975
greater in heavy smokers than in nonsmoking control subjects. It has also been shown that smoking decreases arterial flow, lowers skin temperature, increases carboxyhemoglobin values," 111. 11. "'. :<11. :n. ,r.. 4" affects platelet adhesiveness, and promotes thrombosis." Smoking also directly promotes atherogenesis 1. "" by changing the normal hemodynamic and flow patterns> ~G.:W or by impairing the oxygen transport (Kannel L'">" Any or all of these factors may unfavorably influence the patency of synthetic grafts by acting on the pseudointima of the graft itself, or on the blood flowing through it, or simply by promoting and accelerating already existing atherosclerotic changes in the vessels proximal and distal to the inserted graft. The question naturally arises as to the practical clinical significance of these findings and the observations presented in our study? Although symptoms of peripheral arterial disease may begin relatively early in life, ischemia of the skeletal muscle is better tolerated than ischemia of the brain or the myocardium; the patient can adjust to skeletal muscle ischemia by decreasing his physical activity with advancing age. It is important to realize that often the principal hazard to individuals with moderate circulatory impairment of the legs is not so much the loss of a limb, but rather other cardiovascular catastrophes-such as, stroke, congestive heart disease, and myocardial infarction-and the shortened life span caused by these conditions."-" Based on their symptoms, we can roughly divide patients with occlusive arterial disease of the legs into three principal groups: those who have intermittent claudication only, those who also have pain at rest, and those who have impending or frank gangrene. Whereas in the latter two groups surgery is a necessity, grafting in persons with intermittent claudication only is a matter of clinical judgment. In this judgment, the patient's decision to continue smoking must be weighed heavily and may be regarded as a relatively strong
contraindication to reconstructive vascular surgery. REFERENCES
2
3
4
5
6 7
8
9
10
11
12
13
14
Aurbach, 0., Hammond, E. C., and Garfinkel, L.: Smoking in Relation to Atherosclerosis of Coronary Arteries, N. Eng!. J. Med. 273: 775, 1965. Aurbach, 0., Hammond, E. c., and Garfinkel, L.: Thickening of Walls of Arterioles and Small Arteries in Relation to Age and Smoking Habits, N. Eng!. J. Med. 278: 980, 1968. Barker, N. W.: The Tobacco Factor in Thromboangiitis Obliterans, Mayo Clin. Proc. 6: 65, 1931. Borhani, N. 0., Hechter, H. H., and Breslow, L.: Report of Ten-Year Follow-up Study of San Francisco Longshoremen: Mortality from Coronary Heart Disease and From All Causes, J. Chron. Dis. 16: 1251, 1963. Coffman, J. D., and Javett, S. L.: Blood Flow in Human Calf During Tobacco Smoking, Circulation 28: 932, 1963. Dorn, H. F.: Tobacco Consumption and Mortality From Cancer and Other Diseases, Public Health Rep. 74: 581, 1959. Doyle, J. T., Dawber, T. R., Kannel, W. B., Heslin, A. S., and Kahn, H. A.: Cigarette Smoking and Coronary Heart Disease: Combined Experience of Albany and Framingham Studies, N. Eng!. J. Med. 266: 796, 1962. Doll, R., and Hill, A. B.: Mortality in Relation to Smoking: Ten Years' Observations of British Doctors, Br. Med. J. 1: 1399, 1964. Eastcott, H. H. G. : Rarity of Lower Limb Ischemia in Non-smokers, Lancet 2: 1117, 1962. Felder, D., Russ, E., Montgomery, H., and Horwitz, 0.: Relationship in the Toe of Skin Surface Temperature to Mean Blood Flow Measured With Plethysmograph, Clin. Sci. 13: 251, 1954. Goldsmith, J. R., and Landaw, S. C.: Carbon Monoxide and Human Health, Science 162: 1352, 1968. Hammond, E. c., and Horn, D.: Smoking Death Rates: A Report on Forty-four Months' Follow-up of 187,783 Men. II. Death Rate by Cause, J. A. M. A. 166: 1294, 1958. Hammond, E. C.: Smoking in Relation to Mortality and Morbidity: Findings in First 34 Months of Follow-up in a Prospective Study Started in 1959, J. Natl. Cancer Inst. 32: 1161, 1964. Hammond, E. C.: Smoking in Relation to the Death Rates of One Million Men and Women, in Haenszel, W., editor: Epidemiological Approaches to the Study of Cancer and Other
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17 18
19
20
21
22
23
24
25 26 27 28
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Chronic Diseases, Bethesda, 1966, The National Institutes of Health, pp. 127-204. Hammond, E. C., and Garfinkel, L.: Coronary Heart Disease, Stroke and Aortic Aneurysm: Factors in Etiology, Arch. Environ. Health 19: 167, 1969. Harkavy, J., and Perlam, E.: Tobacco Allergy in Coronary Artery Disease, N. Y. J. Med. 64: 1287, 1964. Hill, P.: Smoking and Cardiovascular Disease: Effect of Nicotine on the Serum Epinephrine and Corticoids, Am. Heart J. 87: 491, 1974. Irving, D. W., and Yamamoto, T.: Cigarette Smoking and Cardiac Output, Br. Heart J. 25: 126, 1963. Juergens, J. L., Barker, N. W., and Hines, E. A.: Arteriosclerosis Obliterans: Review of 520 Cases With Special Reference to Pathogenic and Prognostic Factors, Circulation 21: 188, 1960. Kahn, H. A.: The Dorn Study of Smoking and Mortality Among U. S. Veterans: Report on Eight and a Half Years' Observation, in Haenszel, W., editor: Epidemiological Approaches to the Study of Cancer and Other Chronic Diseases, Bethesda, 1966, The National Institutes of Health, pp. 1-127. Kannel, W. B., Skinner, J. J., Jr., Schwartz, M. J., and Shurtleff, D.: Intermittent Claudication: Incidence in the Framingham Study, Circulation 61: 875, 1970. Kannel, W. B.: Current Status of the Epidemiology of Brain Infarction Associated With Occlusive Arterial Disease, Stroke 2: 295, 1971. Kannel, W. 8., and Shurtleff, D.: The Framingham Study. Cigarettes and the Development of Intermittent Claudication, Geriatrics 8: 61, 1973. Kershbaum, A., and Bellet, S.: Cigarette Smoking and Blood Lipids, J. A. M. A. 187: 132,1964. Lampson, R. S.: Quantitative Study of the Vasoconstriction Induced by Smoking, 1. A. M. A. 104: 1963, 1935. Lord, J. W.: Cigarette Smoking and Peripheral Occlusive Disease, J. A. M. A. 1: 249, 1965. Mustard, J. F., and Murphy, E. A.: Effects of Smoking on Blood Coagulation and Platelet Survival in Man, Br. Med. J. 1: 846, 1963. Nadeau, R. A., and James, T. N.: Effects of Nicotine on Heart Rate Studied by Direct Perfusion of Sinus Node, Am. J. PhysioI. 212: 911, 1967. Redisch, W.: Tobacco Allergy and Vascular Responses, in James, G., and Rosenthal, T.,
30
31
32
33
34 35 36
37 38
39 40
41 42
editors: Tobacco and Health, chap. 24, Springfield, III., 1962, Charles C Thomas, Publisher, pp. 352-359. Roth, G. M., McDonald, J. B., and Sheard, C.: The Effect of Smoking Cigarettes and of Intravenous Administration of Nicotine on the Electrocardiogram, Basal Metabolic Rate, Cutaneous Temperature, Blood Pressure and Pulse Rate of Normal Persons, J. A. M. A. 125: 761, 1944. Roth, G. M.: Tobacco and the Cardiovascular System: The Effects of Smoking and Nicotine on Normal Persons, Springfield, III., 1951, Charles C Thomas, Publisher. Rottenstein, H., Peirce, G., Russ, E., Felder, D., and Montgomery, H.: Influence of Nicotine on the Blood Flow of Resting Skeletal Muscle and on the Digits in Normal Subjects, Ann. N. Y. Acad. Sci. 90: 102, 1960. Sackett, D. L., Gibson, R. W., Bross, I. D. J., and Pickran, J. W.: Relation Between Aortic Atherosclerosis and the Use of Cigarettes and Alcohol: An Autopsy Study, N. EngI. 1. Med. 279: 1413, 1968. Sanger, P. W., Robicsek, F., and Gallucci, V.: Operative Mortality of Aortic Resections, Surgery 64: 359, 1968. Sarin, Ch.L., Austin, J. c., and Nickel, W.O.: Effects of Smoking on Digital Blood-Flow Velocity, J. A. M. A. 229: 1327, 1974. Texon, M., Imparoto, A. M., Lord, J. W., and Helpern, M.: Experimental Production of Arterial Lesions, Arch. Intern. Med. 110: 50, 1962. U. S. Department of Health, Education and Welfare: Surgeon General's Report on Health Consequences of Smoking, 1972. Weinroth, L. A., and Herzstein, J.: Relation of Tobacco Smoking to Arteriosclerosis Obliterans in Diabetes Melitus, J. A. M. A. 131: 205, 1946. Westfall, T. c, and Watts, D. T.: Catecholamine Excretion in Smokers and Non-smokers, J. Appl, PhysioI. 19: 40, 1964. Widmer, L. K., Greensher, A., and Kannel, W. B.: Occlusion of the Peripheral Arteries, Circulation 30: 836, 1964. Wright, I. S., and Moffat, D.: Effects of Tobacco on Peripheral Vascular System, J. A. M. A. 103: 318, 1934. Yao, S. T., Needham, T. N., and Gourmoos, C.: A Comparative Study of Strain Gauge Plethysmography and Doppler Ultrasound in the Assessment of Occlusive Arterial Disease of the Lower Extremities, Surgery 71: 4, 1972.
Francis Robicsek, M.D., Harry K. Daugherty, M.D., Donald C. Mullen, M.D., Thomas N. Masters, Ph.D., Dundar Narbay, M.D., and Paul W. Sanger, M.D., t Charlotte, N. C.
For thy sake, Tobacco, I would do anything, but die. Charles Lamb, 1803
The harmful effects of nicotine abuse upon the cardiovascular system in general- 2, 4, 6-8, 11-18, 20, 22, 24, 25, 27,28, 30, 31, 33, 36, 37, 39 and on the arterial circulation of the lower extremities in particular- 5, 9, 10, 19, 21, 23, 26, 29, 32, 35, 37, 38, 40, 41, 42 have been proved by several independent studies. It is now generally recognized that cigarette smoking is a significant factor in the development and progression of occlusive arteriosclerosis in both coronary and the peripheral circulation. In the surgical management of arterial From the Department of Thoracic and Cardiovascular Surgery and the Heineman Medical Research Laboratories, Charlotte Memorial Hospital, Charlotte, N. C. Received for publication Feb. 3, 1975. tOr. Sanger is deceased.
occlusive disease of the lower abdominal aorta and iliac arteries (Leriche syndrome), we were particularly impressed by two everrecurring observations: ( I ) the disproportionally high percentage of smokers among our patients whose disease was severe enough to warrant surgery and (2) the poor prognosis of those who continued to smoke after the otherwise successful operation. In the following report, we attempt to convert this general observation into a more objective statistical study with the intent of drawing some practical conclusions.
Clinical material and methods During the past decade, a total of 367 consecutive patients have undergone different types of arterial grafting procedures on our service for lower limb ischemia. From the technical viewpoint, these patients
107
The Journal of
10 8
Robicsek et al,
Thoracic and Cardiovascular Surgery
were divided into two major groups: ( 1) patients in whom the graft extended from the abdominal aorta to the iliac or femoral arteries and (2) patients in whom femoropopliteal or femoro-tibial grafting was done. We have found that, in the first group (220 patients), our indication for surgery, the operative technique, and the graft material changed very little during the past 15 years. Therefore, the patients represented a fairly uniform study material. By comparison, in the second group (147 patients), all three of these factors changed considerably during this time period. The statistical study of the latter group would have necessitated a further breakdown of patients into subgroups so small that their evaluation would have been meaningless. Our general clinical impression on the effects of smoking on the patency of arterial bypass grafts in the two groups was about the same. However, for the reasons mentioned, we decided to limit our observations to patients belonging to the first group, in whom the principal occlusive site was the lower aorta and the iliac system (Leriche syndrome). All the patients included in the study suffered from circulatory deficit of the lower extremities, their symptoms varying from intermittent claudication to frank gangrene of the toes. Before the operation, angiographic studies were performed in all patients. The surgical procedure consisted of a midline laparotomy, exploration of the abdominal aorta, the iliac artery, and if it appeared necessary, the femoral vessels. The narrowed or occluded vascular segment was replaced in some and bypassed in others with a bifurcated vascular prosthesis made of woven Dacron. The graft was anastomosed to the aorta proximally and to the iliac or common femoral vessels distally. In a number of cases, the extent of the disease also necessitated an endarterectomy and/or arterioplasty of the vascular segment lying immediately proximal or distal to the anastomotic connections. Of 220 patients, 207 survived the opera-
tion and left the hospital alive. They were followed as outpatients at regular intervals, at which time they were questioned about their smoking habits and were examined clinically. Absence of one or both femoral pulses within 3 months after the operation was probably due to either misjudging the available vascular bed for graft-flow runoff, to faulty operative technique, or both. This criterion also eliminated a small, but nonetheless significant, number of patients (11) from further study. Thirteen patients who smoked a pipe or cigar or who chewed or snuffed tobacco were also excluded from the study, because of the statistically insignificant size of this group. Results
Of the 183 patients, 159 were followed either to the date of the study or until the disappearance of their femoral pulse, which implied occlusion of the graft. Sixteen patients were lost to follow-up, and 11 patients died of causes unrelated to the operation. The time period between the operation and their last office visit, when the patency of the graft was still confirmed, was also included in this study. Group I was composed of 10 patients, 4 of whom were women, who did not smoke either before or after the operation. Four of them had aorto-iliac and 6 had aortofemoral grafts (or an aorto-iliac graft on one side and an aorto-femoral graft on the other). The average age of the patients was 53 years. Four had a history of diabetes mellitus. During this period of 502 follow-up months (for the whole group), none of the grafts became occluded. Group II included 95 patients, 15 of whom were women, who were cigarette smokers before surgery but quit their habit after the operation. Fourteen were treated by aorto-iliac grafting and 81 aorto-femoral grafting. The average age was 56 years. Nineteen of these patients had diabetes. Within a period of 4,489 follow-up months, there were 10 graft occlusions or an occlusion rate of 1/448 months.
Volume 70 Number 1
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Effect of cigarette smoking in vascular disease
July, 1975
Group III comprised 52 patients, including 10 women. They were cigarette smokers before surgery and continued to smoke after the operation, but less than a pack a day. Twenty-six had aorto-iliac and 26 had aorto-femoral grafts. The average age of the patients was 5 I, and there were 7 who had diabetes. During a period of 2,757 follow-up months, 8 grafts became occluded, for an occlusion rate of 1/342 months. Group IV was formed by 26 patients who remained heavy smokers after the operation and consumed more than a pack of cigarettes a day. Eight underwent aorto-iliac grafting and the other 18 underwent aortofemoral grafting. Of the 7 women and 19 men included in this group, 7 had diabetes. The average age of the group was 56 years. This group was observed for a total of 1,093 follow-up months, during which 8 graft occlusions occurred, for an occlusion rate of 1/137 follow-up months. Group V represented the 105 patients already described in Groups I and II, i.e., all the individuals who did not smoke after surgery. There were 18 aorto-iliac and 87 aorto-femoral grafts. Nineteen of these patients were women and 88 men, with an average age of 55 years. Twenty-three of them had a history of diabetes. The combined follow-up time for this group was 4,991 months, during which 10 graft occlusions occurred. This represents an occlusion rate of 1/499 follow-up months. Group VI was composed of 78 patients described in Groups III and IV, 17 of them women. There were 34 aorto-iliac and 44 aorto-femoral grafts. The average age of the total group was 54 years, and 14 patients had diabetes. During the total follow-up period of 3,850 months, there were 16 graft occlusions or an occlusion rate of 1/240 follow-up months. A graphic display of the data of the six groups is given in Figs. 1 to 3. The possible result of a patient's decision to continue smoking is shown in Fig. 4.
I
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I i · 0l-v 0 1e 8 0 0 P Fig. 1. Graph showing the state of patency of bifurcated Dacron woven grafts. The Roman numerals represent the following groups: I, those who did not smoke before or after surgery; II, those who quit smoking after surgery; Ill, those who continued to smoke less than one pack a day after surgery; IV, those who continued to smoke more than one pack a day after surgery; V, all nonsmokers after surgery; VI, all smokers after surgery. The vertical Column A's are aortoiliac grafts. The vertical Column B's are aortofemoral grafts. The white circles represent open grafts, and the black circles represent occluded grafts. The vertical calibration represents years of observation and/or the time at graft occlusion.
Comments The pathological processes of occlusive arteriosclerosis occurring in the heart, head, and peripheral vessels appear to be identical. Cigarette smoking has been shown to be one of the most important factors in coronary heart disease and stroke;'- 4, 6-8, 12-10, 18, .20, 22, '" and it would be most strange if this were not also true for disease of the peripheral arteries. .In 1962, Eastcott" wrote: "I now never diagnose atheroma as a cause of ischemia (of the legs) in a male non-smoker." Although this may be
The Journol of
1 10
Robicsek et af.
Thoracic and Cardiovascular Surgery
%
Occlosion
Rale
40
30
20
10
Group
I
:IT
ill
N:
Fig. 2. Occlusion rate of bifurcated Dacron woven grafts. For explanation of groups, see Fig. 1.
II Ocelo. lo. hte
Fig. 3. Occlusion rate per observation month in the different groups . For explanation of groups see Fig . 1.
somewhat overstated, it is certain that leg ischemia caused by arteriosclerosis is very rare in the nonsmoker. Lord. t" reviewing the charts of 100 consecutive patients operated upon for peripheral arterial disease of the aorto-iliac tree or of the femoro-popliteal arteries , found only 2 nonsmokers among them. Kannel and Shurtleff;" interpreting the data obtained by the Framingham study based on 16 years of cardiovascular surveillance of more than 5,000 subjects, also found a "striking relationship"
Fig. 4. Is it worth it?
between the habit of cigarette smoking and the rate of occurrence of intermittent claudication. Similar observations have been reported by Weinroth and Herzstein," by Juergens, Barker and Hines, III and by others. Our study , which was done on 183 consecutive patients operated upon for Leriche syndrome, not only has confirmed these observations but has made another point: It has proved that if the victim of tobacco addiction continues to smoke after an otherwise successful grafting procedure, the risk of graft occlusion at a later period is much higher than in those who quit smoking cigarettes. There is ample evidence that the nicotine absorbed from inhaled cigarette smoke has effects on the circulation. Mustard and Murphy'" have shown that cigarette smoking shortens platelet survival and accelerates blood coagulation. Kershbaum and Beller" have demonstrated that cigarette smoking causes a rapid and consistent rise in serum free fatty acids and increases the excretion of urinary catecholamines. Westfall and Watts '" found that the rate of excretion of both epinephrine and catecholamines is
Volume 70 Number 1
Effect of cigarette smoking in vascular disease
I I I
July, 1975
greater in heavy smokers than in nonsmoking control subjects. It has also been shown that smoking decreases arterial flow, lowers skin temperature, increases carboxyhemoglobin values," 111. 11. "'. :<11. :n. ,r.. 4" affects platelet adhesiveness, and promotes thrombosis." Smoking also directly promotes atherogenesis 1. "" by changing the normal hemodynamic and flow patterns> ~G.:W or by impairing the oxygen transport (Kannel L'">" Any or all of these factors may unfavorably influence the patency of synthetic grafts by acting on the pseudointima of the graft itself, or on the blood flowing through it, or simply by promoting and accelerating already existing atherosclerotic changes in the vessels proximal and distal to the inserted graft. The question naturally arises as to the practical clinical significance of these findings and the observations presented in our study? Although symptoms of peripheral arterial disease may begin relatively early in life, ischemia of the skeletal muscle is better tolerated than ischemia of the brain or the myocardium; the patient can adjust to skeletal muscle ischemia by decreasing his physical activity with advancing age. It is important to realize that often the principal hazard to individuals with moderate circulatory impairment of the legs is not so much the loss of a limb, but rather other cardiovascular catastrophes-such as, stroke, congestive heart disease, and myocardial infarction-and the shortened life span caused by these conditions."-" Based on their symptoms, we can roughly divide patients with occlusive arterial disease of the legs into three principal groups: those who have intermittent claudication only, those who also have pain at rest, and those who have impending or frank gangrene. Whereas in the latter two groups surgery is a necessity, grafting in persons with intermittent claudication only is a matter of clinical judgment. In this judgment, the patient's decision to continue smoking must be weighed heavily and may be regarded as a relatively strong
contraindication to reconstructive vascular surgery. REFERENCES
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