Smoking-Thrombectomy Paradox: A Prospective Single-Center Study on the Impact of Smoking Status on Reperfusion Rates

BackgroundSmoking is a well-established risk factor for acute ischemic stroke, but its influence on endovascular thrombectomy outcomes remains unclear. While previous studies suggested a "smoking paradox" in thrombolysis, evidence regarding EVT is limited. MethodsWe conducted a prospective, single-center observational study of 169 patients with acute ischemic stroke who underwent EVT between January 2019 and March 2023, using data from a tertiary hospital thrombectomy database in Kaohsiung, Taiwan. Patients were categorized as smokers (n=52) or non-smokers (n=117). Baseline characteristics were adjusted using inverse probability of treatment weighting. The primary endpoint was complete reperfusion. Secondary outcomes included NIHSS scores at admission and 24 hours post-procedure, modified Rankin Scale at discharge, and complications. ResultsSmokers were younger and more often male, with lower rates of atrial fibrillation. After IPTW adjustment, smokers had significantly lower rates of complete reperfusion compared to non-smokers (30% vs. 53%; OR 0.39; 95% CI 0.19-0.79; p=0.01). They also presented with higher NIHSS scores at admission and 24 hours post-thrombectomy (p<0.05), and an increased risk of stroke-associated pneumonia (OR 2.98; p=0.003). No significant difference in discharge mRS was observed. ConclusionsSmoking is associated with reduced reperfusion success, worse neurological status, and higher pneumonia risk after EVT, but not with short-term functional outcome. These findings contradict the notion of a smoking-reperfusion paradox in EVT-treated AIS patients.