Factors Associated with and Outcomes of Respiratory Adverse Events Following Thoracic Endovascular Aortic Repair

ARTICLE HIGHLIGHTSType of Research: Retrospective analysis of prospectively collected Vascular Quality Initiative registry data.Key Findings: In patients undergoing TEVAR, risk factors for developing respiratory adverse events (RAEs) include male sex, obesity, renal dysfunction, disease location in the arch or ascending aorta, anemia, COPD on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, being bedbound and intra-operative transfusion. Developing RAEs is associated with a two-fold increase in 5-year mortality rate, independent of other post-operative complications.Take home Message: This study identifies patients at higher risk of developing respiratory adverse events (RAEs) following TEVAR and underscores the importance of preventing these events to improve outcomes. Despite the lack of guidelines on reducing RAEs post-TEVAR, personalized lung protective post-operative care could enhance patient outcomes.ABSTRACTObjectiveRespiratory adverse events (RAEs) after thoracic endovascular aortic repair (TEVAR) remain poorly characterized due 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.MethodsWe identified Vascular Quality Initiative patients undergoing TEVAR isolated to zones 0-5 from 2010 to 2023 for non-traumatic pathologies. After determining the incidence of post-operative 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 pre- and intra-operative variables independently associated with the development of postoperative RAEs using multivariable modified Poisson regression. Kaplan-Meier analysis and Cox proportional hazards regression model were used to determine associations between postoperative RAEs and 5-year survival adjusting for preoperative variables and other non-respiratory post-operative complications in a separate model.ResultsOf 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 post-TEVAR was associated with male sex (aRR: 1.19 [95% CI: 1.01-1.41]; p=0.037), obesity (1.31[1.07-1.61]; p=0.009), morbid obesity (1.68[1.20-2.32]; p=0.002), renal dysfunction (eGFR 30-45: 1.45[1.15-1.82]; p=0.002; eGFR <30/hemodialysis: 1.7[1.37-2.11]; p<0.001), anemia (1.31[1.09-1.58]; p=0.003), aortic diameter >65mm (1.54[1.25-1.89]; p<0.001), proximal disease in the aortic arch (1.23[1.03-1.48]; p=0.025) or ascending aorta (1.61[1.19-2.14]; p=0.002), acute aortic dissection (2.13[1.72-2.63]; p<0.001), ruptured presentation (3.07[2.43-3.87]; p<0.001), same-day surgical thoracic branch treatment (1.51[1.25-1.82]; p<0.001), COPD on home oxygen (1.58[1.08-2.25]; p=0.014), limited self-care or bed-bound status (2.12[1.45-3.03]; p<0.001), and intraoperative transfusion (1.88[1.47-2.40]; p<0.001). Patients who developed post-operative RAEs had higher 30-day mortality (27% vs 4%; p<.001) and 5-year mortality than patients without respiratory complications (46% vs 20%; p<0.001). After adjusting for pre-operative and post-operative variables, 5-year mortality was higher in patients who developed any post-operative RAE (aHR: 1.8[1.6, 2.1]; p<.001), post-operative pneumonia only (1.4[1.0, 1.8];p=.046), reintubation only (2.2[1.8, 2.6]; p<.001) or both (1.5[1.1, 2.0]; p=.008).ConclusionsRAEs after TEVAR are common, more likely to occur in male patients with obesity, renal dysfunction, anemia, COPD on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, who received intra-operative transfusion, and are associated with a two-fold increase in 5-year mortality regardless of the development of other post-operative complications. Considering these factors in assessing risks and benefits of TEVAR procedures, along with implementing customized post-operative care, can potentially improve clinical outcomes.