Airway Complications Following Lung Transplantation Using Prolonged 10°C Controlled Graft Preservation

Static cold storage (SCS) at 10°C safely extends donor lung preservation, but its effect on bronchial anastomotic healing remains incompletely characterized. This study evaluates the association between 10°C SCS and incidence of airway complications relative to conventional ice preservation in adult lung transplant recipients.

Adult lung transplants performed between January 2020 and May 2025 at a single large academic medical center were reviewed, and multiorgan transplants were excluded. Institutional preservation protocol changed from ice to 10°C in 2023. 10°C recipients were 1:1 propensity score matched to ice-preserved recipients. Airway complications (ischemia/necrosis, dehiscence, stenosis, and malacia) were graded by two independent reviewers using 2018 ISHLT consensus criteria and compared between cohorts. Multivariable regression was used to assess the association between 10°C preservation and ischemia/necrosis and stenosis. Recipients of 10°C-preserved allografts were further stratified by an 18-hour total preservation time threshold, and incidence of complications were evaluated between groups.

A total of 138 recipients of 10°C preserved allografts (130 bilateral and 8 single lung) were matched to 138 controls, yielding 268 anastomoses per group. The median graft ischemic time in the 10°C group was 10.7 hours (interquartile range [IQR]: 6.5 - 17.4 hours) compared to 5.7 hours (IQR: 4.3 - 8.2 hours) in the ice group. Among 10°C graft recipients, 34 (24.6%) received at least one graft with a preservation time ≥18 hours. 10°C-preserved allografts had a slightly lower incidence of ischemia/necrosis than ice-preserved allografts (21.6% vs 29.5%, p=0.048). Rates of dehiscence, stenosis requiring intervention, and malacia were comparable. Median time to first intervention for stenosis did not differ between groups (3.1 vs 3.5 months, p>0.999). After adjustment for donor and recipient attributes associated with anastomotic complications, 10°C preservation was independently associated with reduced ischemia/necrosis (relative risk [RR] 0.55, 95% confidence interval[CI] 0.35-0.85, p=0.007), with consistent effects in the <18-hour (RR 0.54, 95% CI: 0.34 - 0.86) and ≥18-hour (RR 0.56, 95% CI: 0.30 - 1.02) subgroups. Ischemia/necrosis was the main driver for subsequent stenosis (RR 3.83, 95% CI 1.74 - 8.43, p<0.001). Notably, prolonged 10°C preservation ≥18 hours was not associated with an increased rate of stenosis.

10°C static cold storage does not increase anastomotic airway complications relative to conventional ice storage, even at total preservation times ≥18 hours. In this analysis, it was even associated with reduced early anastomotic ischemia and necrosis. These findings extend the safety profile of 10°C preservation and support its continued clinical adoption.