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Partial Diaphragm Division Is Associated With Decreased Ventilator Support After Open Thoracoabdominal Aortic Repair
Abdul Kader Natour, M.D., Thomas C. Bower, MD, Alberto Pochettino, MD, Bernardo C. Mendes, MD, Venkata Vineeth Vaddavalli, MBBS, Manju Kalra, MBBS, Randall R. DeMartino, MD, Jill Colglazier, MD.
Mayo Clinic, Rochester, MN, USA.
OBJECTIVES: The most frequent 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 and overall outcomes in patients undergoing OTAAR.
METHODS: Retrospective single-institutional review of patients who underwent extent I-V OTAAR between 2013 and 2024. Patients who did not require diaphragm division were excluded. Outcomes were analyzed in two groups based on complete or partial diaphragm division. The primary outcome was prolonged ventilation, defined as postoperative ventilator support >48 hours. Secondary outcomes included early respiratory morbidity, in-hospital mortality, major adverse events, ICU and hospital stay. Univariate followed by multivariate analysis was used to evaluate the association of extent of diaphragm division with the primary and secondary outcomes.
RESULTS: Among 135 patients who underwent OTAAR during the study period, 110 patients met the inclusion criteria and were included in the analysis. Average age was 54 ±14 years, and 70% (n=77) were male. Most repairs were done for post-dissection aneurysms (75%, n=83) requiring extent II thoracoabdominal aortic repair (82%, n=91). Demographics, comorbidities and preoperative variables were similar between the two groups (Table 1). Full circumferential diaphragm division (FCD) was performed in 54% of these patients (n=60), while 46% (n=50) had partial division (PD). Prolonged ventilation occurred in 25 patients (24%). On univariate analysis, patients who underwent FCD were more likely to have prolonged ventilation as compared to those who had PD (32%, n=18 vs 15%, n=7, p=0.037) (Table 1). This association persisted on multivariate analysis (odds ratio; 4.0, CI; 1.4-11.8, p=0.01). Patients who had FCD were more likely to have postoperative pneumonia (35% vs 25%), need for re-intubation (16% vs 8%) and ICU readmission (20% vs 10%), but these did not reach statistical significance. No significant difference was seen when comparing in-hospital mortality, ICU and hospital stay, stroke, myocardial infarction, and renal failure requiring dialysis.
CONCLUSIONS: Partial division of the diaphragm is associated with a lower incidence of postoperative mechanical ventilation but without any impact on mortality or morbidity. Partial diaphragm division should be considered in OTAAA repairs.
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