Partial diaphragm division is associated with decreased ventilator support after open thoracoabdominal aortic repair

The most common complications of open thoracoabdominal aortic repair (OTAAR) are respiratory in nature. The aim of this study was to analyze the impact of intraoperative diaphragm management on prolonged postoperative ventilation, pulmonary complications, and overall outcomes in patients undergoing OTAAR.

We conducted a retrospective single-institutional review of patients who underwent extent I to V OTAAR between 2013 and 2024. Patients who did not require diaphragm division were excluded. Outcomes were analyzed in two groups based on full circumferential division (FCD) or partial circumferential division (PD). The primary outcome was prolonged ventilation, defined as postoperative ventilator support for >48 hours. Secondary outcomes included early respiratory morbidity, in-hospital mortality, major adverse events, and length of intensive care unit (ICU) and hospital stays. Univariate followed by multivariable analyses were used to evaluate the association of extent of diaphragm division with the primary and secondary outcomes.

Among 135 patients who underwent OTAAR during the study period, 110 patients met the inclusion criteria and were included in the analysis. The average patient age was 54 ±14 years, and 77 patients (70%) were male. Most repairs were done for postdissection aneurysms (n = 83 [76%]) requiring extent II thoracoabdominal aortic repair (n = 88 [80%]). Demographics, comorbidities, and preoperative variables were similar between the two groups. FCD was performed in 60 patients (54%), and 50 patients (46%) underwent PD. Prolonged ventilation occurred in 25 patients (24%). On univariate analysis, patients who underwent FCD were more likely to have prolonged ventilation as compared with those who underwent PD (32% [n = 18] vs 15% [n = 7]; P = .037). This association persisted on multivariable analysis (odds ratio, 4.0; 95% confidence interval, 1.4-11.8; P = .01). Patients who underwent FCD demonstrated a trend toward higher rates of postoperative pneumonia (35% vs 25%), need for reintubation (16% vs 8%), and ICU readmission (20% vs 10%). No significant differences were seen when comparing in-hospital mortality, length of ICU and hospital stays, cerebrovascular accident, myocardial infarction, or renal failure requiring dialysis.

PD of the diaphragm is associated with a shorter duration of postoperative mechanical ventilation without any significant impact on mortality or major adverse events. PD should be considered for OTAARs.