Factors associated with and outcomes of respiratory adverse events following thoracic endovascular aortic repair

Objective: Respiratory adverse events (RAEs) after thoracic endovascular aortic repair (TEVAR) remain poorly characterized owing to the lack of comprehensive studies that identify individuals prone to these complications. This study aims to determine the incidence, factors associated with, and outcomes of RAEs after TEVAR. Methods: We identified patients in the Vascular Quality Initiative undergoing TEVAR isolated to zones 0 to 5 from 2010 to 2023 for nontraumatic pathologies. After determining the incidence of postoperative RAEs, we assessed baseline characteristics, pathology, procedural details, and postoperative complications stratified by respiratory complication status: none, pneumonia only, reintubation only, or both. We then examined preoperative and intraoperative variables independently associated with the development of postoperative RAEs using multivariable modified Poisson regression. Kaplan-Meier analysis and Cox proportional hazards regression models were used to determine associations between postoperative RAEs and 5-year survival adjusting for preoperative variables and other nonrespiratory postoperative complications in a separate model. Results: Of 10,708 patients, 8.3% had any RAE (pneumonia only, 2.1%; reintubation only, 4.8%; both, 1.4%). Patients with any RAE were more likely to present with aortic dissection (any respiratory complication, 46% vs no respiratory complication, 35%; P < .001), and be symptomatic (58% vs 48%; P < .001). Developing RAEs after TEVAR was associated with male sex (adjusted relative risk [aRR], 1.19; 95% confidence interval [CI], 1.01-1.41; P = .037), obesity (aRR, 1.31; 95% CI, 1.07-1.61; P = .009), morbid obesity (aRR, 1.68; 95% CI, 1.20-2.32; P = .002), renal dysfunction (aRR, estimated glomerular filtration rate 30-45, 1.45; 95% CI, 1.15-1.82; P = .002; estimated glomerular filtration rate <30/hemodialysis, 1.7; 95% CI, 1.37-2.11; P < .001), anemia (aRR, 1.31; 95% CI, 1.09-1.58; P = .003), aortic diameter >65 mm (aRR, 1.54; 95% CI, 1.25-1.89; P < .001), proximal disease in the aortic arch (aRR, 1.23; 95% CI, 1.03-1.48; P = .025) or ascending aorta (aRR, 1.61; 95% CI, 1.19-2.14; P = .002), acute aortic dissection (aRR, 2.13; 95% CI, 1.72-2.63; P < .001), ruptured presentation (aRR, 3.07; 95% CI, 2.43-3.87; P < .001), same-day surgical thoracic branch treatment (aRR, 1.51; 95% CI, 1.25-1.82; P < .001), chronic obstructive pulmonary disease on home oxygen (aRR, 1.58; 95% CI, 1.08-2.25; P = .014), limited self-care or bed-bound status (aRR, 2.12; 95% CI, 1.45-3.03; P < .001), and intraoperative transfusion (aRR, 1.88; 95% CI, 1.47-2.40; P < .001). Patients who developed postoperative RAEs had higher 30-day mortality (27% vs 4%; P < .001) and 5-year mortality than patients without respiratory complications (46% vs 20%; P < .001). After adjusting for preoperative and postoperative variables, the 5-year mortality was higher in patients who developed any postoperative RAE (adjusted hazard ratio [aHR], 1.8; 95% CI, 1.6, 2.1; P < .001), postoperative pneumonia only (aHR, 1.4; 95% CI, 1.0, 1.8; P = .046), reintubation only (aHR, 2.2; 95% CI, 1.8, 2.6; P < .001) or both (aHR, 1.5; 95% CI, 1.1, 2.0; P = .008). Conclusions: RAEs after TEVAR are common, more likely to occur in male patients with obesity, renal dysfunction, anemia, chronic obstructive pulmonary disease on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, who received intraoperative transfusion, and are associated with a two-fold increase in 5-year mortality regardless of the development of other postoperative complications. Considering these factors in assessing the risks and benefits of TEVAR procedures, along with implementing customized postoperative care, can potentially improve clinical outcomes.