Wound Healing/Plastic Surgery
Smoking and wound complications after coronary artery bypass grafting

https://doi.org/10.1016/j.jss.2015.09.017Get rights and content

Abstract

Background

The harmful effects of smoking on the postsurgical wound healing disturbances have been widely investigated across various surgical procedures. These effects after coronary artery bypass graft (CABG) surgery have been less explored. We aimed to investigate the association of smoking and the wound healing problems in post-CABG patients.

Materials and methods

We compared the incidence of wound complications in 405 smokers and 405 nonsmokers who underwent an elective CABG surgery. The incidence of leg and sternal wound complications was evaluated during the first 7 d as well as at a 6-wk postoperative visit.

Results

One hundred fifty-six leg wound complications were noted in 132 patients (16.3%). The overall rate of leg wound healing disturbances was significantly higher in smokers than those in nonsmokers (odds ratio, 1.47; 95% confidence interval, 1.109–4.019; P = 0.010). The incidence rates of leg wound edge necrosis and dehiscence were significantly higher in smokers compared with those in nonsmokers (3.7% versus 0.7%, P = 0.004 and 6.6% versus 0.7%, P < 0.0001, respectively). We found no significant differences between the incidence of postoperative leg wound infection, hematoma, wound edema, and seroma in active smokers and those who never smoked. Thirty-seven postsurgical sternal wound complications (4.6%) were developed in 33 patients (4.1%). The overall rate of sternal wound healing disturbances was similar between smokers and nonsmokers. There was a trend between the sternal wound dehiscence and smoking (P = 0.03); however, the other sternal wound complications were not associated with smoking.

Conclusions

Smoking may contribute to the disturbances of wound healing, especially wound dehiscence, in post-CABG patients.

Introduction

Arterial conduits are widely preferred for coronary revascularization; however, great saphenous veins are still commonly used in most coronary artery bypass graft (CABG) surgeries [1]. Despite improvements in surgical techniques and perioperative care, leg and sternal wound healing disturbances remain significant causes of postoperative morbidity, impaired quality of life, and increased inhospital stay among patients undergoing CABG. The rates of sternal and leg wound healing complications after CABG surgery range from 0.5%–10% and 1%–44%, respectively [2], [3], [4], [5], [6], [7], [8]. Female gender, diabetes mellitus, obesity, and peripheral vasculopathies have been identified as significant independent predictors of post-CABG wound complications [9], [10], [11]. Also, smoking has been shown to be associated with wound healing complications after several types of surgeries [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23]; however, the potential role of smoking as an independent contributor to the post-CABG wound healing disturbances has been less explored.

In this study, we aimed to compare the incidence of leg and sternal wound complications in two groups of post-CABG smoker and nonsmoker patients.

Section snippets

Study design and population

A total of 810 patients including 405 smokers and 405 nonsmokers who had undergone an elective CABG surgery were enrolled consecutively between June 2007 and August 2013. The patients were excluded if (1) they were found to be immunocompromised or on steroids within the 3 mo before surgery, (2) they were unable to complete follow-up, and (3) the procedure involved the use of only arteries as conduits for myocardial revascularization. The demographic characteristics of patients and data

Results

No patients were lost to follow-up, and all the patients were evaluated in terms of postoperative leg and sternal wound complications within the first 7 d as well as at 6-wk postsurgical visit.

The univariate comparison of demographic and preoperative clinical characteristics between smokers and nonsmokers is listed in Table 1. There was no significant difference between groups with respect to demographics and known risk factors of wound complications. The prevalence of COPD, however, was

Discussion

To the best of our knowledge, this is one of the largest prospective studies to date evaluating the association of smoking with the incidence of both leg and sternal wound complications in post-CABG patients. In this study, the overall rate of wound complications was 19.2% for leg and 4.6% for sternal incisions in post-CABG patients. The reported rates of wound complications after CABG are inconsistent among different studies [2], [3], [4], [5], [6], [7], [8]. This interstudy variability could

Conclusions

In this study, we demonstrated that smoking is an independent predictor of wound dehiscence and skin necrosis after CABG surgeries. Further studies are needed to confirm the findings of the present study, to address the drawbacks of previous studies and to assess the applicability of these results in daily medical practice.

Acknowledgment

Authors' contributions: P.S. and B.S.-K. contributed to the conception of the study. P.S., B.S.-K., and M.-H.M. did the design of the work. P.S., M.-H.M., L.S., N.B., G.H., and H.S. did the acquisition of the study. P.S. did the analysis and interpretation of data for the work, literature search, and drafting the work. B.S.-K. did the revising and approving the final version of the article for submission. M.-H.M. contributed to the provision of materials, patients, and resources. L.S., N.B.,

References (41)

  • A. Saxena et al.

    Impact of smoking status on early and late outcomes after isolated coronary artery bypass graft surgery

    J Cardiol

    (2013)
  • R. Gunay et al.

    eComment: leg wound morbidities after saphenous vein harvesting techniques. Which is better?

    Interact Cardiovasc Thorac Surg

    (2010)
  • G. Nasso et al.

    Minimally invasive saphenous vein harvesting guided by preoperative echotomography: results of a prospective randomized study

    Interact Cardiovasc Thorac Surg

    (2005)
  • R.S. Khalafi et al.

    Topical application of autologous blood products during surgical closure following a coronary artery bypass graft

    Eur J Cardiothorac Surg

    (2008)
  • D. Jonkers et al.

    Prevalence of 90-days postoperative wound infections after cardiac surgery

    Eur J Cardiothorac Surg

    (2003)
  • K.B. Allen et al.

    Risk factors for leg wound complications following endoscopic vs. traditional saphenous vein harvesting

    Heart Surg Forum

    (2000)
  • I. Kayacioglu et al.

    The risk factors affecting the complications of saphenous vein graft harvesting in aortocoronary bypass surgery

    Tohoku J Exp Med

    (2007)
  • L.V. Doering et al.

    Depression, healing, and recovery from coronary artery bypass surgery

    Am J Crit Care

    (2005)
  • J.E. Siana et al.

    The effect of cigarette smoking on wound healing

    Scand J Plast Reconstr Surg Hand Surg

    (1989)
  • L.T. Sørensen et al.

    Smoking is a risk factor for incisional hernia

    Arch Surg

    (2005)
  • Cited by (16)

    • Risk factors for post sternotomy wound complications across the patient journey: A systematised review of the literature

      2022, Heart and Lung
      Citation Excerpt :

      The interaction between these factors are complex and multifaceted. For instance the impact of smoking is recorded in a number of studies,29,49 with rates of dehiscence 3.5 folds higher in those who consumed >20 cigarettes per day than in those who smoked <20 cigarettes per day.49 The relationship between smoking and COPD is well established,50 so it is perhaps of no surprise that both are identified as risk factors.

    • Risk factors associated with longer stays in cardiovascular surgical intensive care unit after CABG

      2022, Journal of the Formosan Medical Association
      Citation Excerpt :

      Data for the process factors included 3-day averaged laboratory values for organic function, including creatinine kinase (CK), creatinine kinase MB (CK-MB), ratio of arterial oxygen partial pressure to inspired oxygen fraction (PaO2/FiO2 ratio), total bilirubin, creatinine, white blood cell (WBC) count and body temperature via Swan–Ganz catheter. Those represent risk of infection, organic function and comorbidity of CABG followed with the US Centers for Disease Control and Prevention guidelines (Fig. 2).1,5–8,13,14,17,30,31 All data were analyzed using SPSS 22.0 software (SPSS Inc, Chicago, IL, USA).

    • Smoking cessation: Adherence based on patients’ illness perception after coronary artery bypass grafting surgery

      2018, Indian Heart Journal
      Citation Excerpt :

      Smoking can increase the rate of myocardial infarction several folds in patients with cardiovascular diseases.7 Many studies showed that smoking after CABG could increase the risk of CAD recurrence, potentially leading to pulmonary complications, myocardial infarction, the disturbances of wound healing, hospital readmission, and even death.8–10 Many of studies showed that smoking might predict serious post-operative complications after CABG.11,12

    View all citing articles on Scopus
    1

    Equal first authors.

    View full text