Airway complications following lung transplantation using prolonged 10 °C controlled graft preservation

Static cold storage 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 static cold storage 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. The 10 °C recipients were 1:1 propensity score matched to ice-preserved recipients. Airway complications (ischemia/necrosis, dehiscence, stenosis, and malacia) were graded by 2 independent reviewers using 2018 International Society for Heart and Lung Transplantation 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 the incidence of complications was 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, 6.5-17.4 hours) compared with 5.7 hours (interquartile range, 4.3-8.2 hours) in the ice group. Among 10 °C graft recipients, 34 (24.6%) received at least 1 graft with a preservation time 18 hours or more. The 10 °C-preserved allografts had a slightly lower incidence of ischemia/necrosis than ice-preserved allografts (21.6% vs 29.5%, P = .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 > .999). After adjustment for donor and recipient attributes associated with anastomotic complications, 10 °C preservation was independently associated with reduced ischemia/necrosis (relative risk, 0.55, 95% CI, 0.35-0.85, P = .007), with consistent effects in the less than 18 hours (relative risk, 0.54, 95% CI, 0.34-0.86) and 18 hours or more (relative risk, 0.56, 95% CI, 0.30-1.02) subgroups. Ischemia/necrosis was the main driver for subsequent stenosis (relative risk, 3.83, 95% CI, 1.74-8.43, P < .001). Notably, prolonged 10 °C preservation 18 hours or more was not associated with an increased rate of stenosis.

The 10 °C static cold storage does not increase anastomotic airway complications relative to conventional ice storage, even at total preservation times of 18 hours or more. 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.