A systematic review and meta-analysis on the association of smoking with outcomes after lower-limb revascularization

Abstract Objective Smoking is an established risk factor for peripheral artery disease and its complications. However, its impact on post-interventional outcomes after lower-limb revascularization remains inconsistently reported. This systematic review and meta-analysis evaluates the associations between smoking or tobacco use and major clinical adverse outcomes following lower-limb revascularization. Methods A comprehensive literature search of PubMed, Cochrane library and Scopus was conducted up to 8 September 2025. Loss of vessel patency was defined as the primary outcome, reflecting the patency-focused search strategy, while wound healing, amputation, and overall survival were analysed as secondary outcomes. Studies that reported odds ratios (OR), hazard ratios (HR), or risk ratios (RR) for established smoking-related outcomes after endovascular or open revascularization were included. Random-effects models were used to pool effect estimates. Results A total of 41 studies with 238 617 patients were included. The pooled prevalence of smoking was 73.9%, ranging from 8.2% to 87.6%. Smoking was associated with increased risk for loss of patency (OR 1.23, 95% CI 1.00–1.50; HR 1.34, 95% CI 1.13–1.58), amputation or limb loss (HR 1.60, 95% CI 1.01–2.52), and worse overall survival (HR 1.58, 95% CI 0.87–2.88). With wound healing, no significant effect was found (HR 1.04, 95% CI 0.89–1.23). In analyses restricted to current smokers, the composite HR for any adverse outcomes was 1.52 (95% CI 1.17-1.98). Conclusions Smoking was associated with less favourable revascularization outcome, including higher risks of restenosis and amputation, and a non-significant trend towards worse overall survival. Because the certainty of evidence ranged from low to very low, these results represent associations rather than causal effects. These findings reinforce the importance of smoking cessation as a vital component of perioperative management in vascular surgery. Overall certainty of evidence ranged from very low to low across all outcomes.