BACKGROUND: This study assessed the association between chronic obstructive pulmonary disease (COPD) severity and postoperative mortality among patients undergoing thoracic endovascular aortic repair (TEVAR) and complex endovascular aortic repair (CEVAR). METHODS: A retrospective review of the Vascular Quality Initiative database identified elective TEVAR and CEVAR cases from 2013 to 2022, with endograft proximal landing zone ≥2 for thoracic or complex abdominal aortic disease. Symptomatic diseases, ruptures, and urgent or emergent surgeries were excluded. Patients were stratified by COPD severity. The primary outcome was in-hospital mortality. Secondary outcomes included respiratory complications and 1-year mortality. Multivariable logistic regression was used for in-hospital mortality, respiratory complications, and 1-year mortality. RESULTS: Among 11,336 patients with TEVAR and CEVAR, 66% did not have COPD, 9% had COPD not on medications, 20% had COPD on medications, and 6% had COPD on home supplemental oxygen. In-hospital mortality was 2.3%, 3.7%, 3.2%, and 4.5% (P = 0.0004) respectively, and was not associated with increased odds of mortality. Respiratory complications occurred in 4.3%, 4.5%, 6.4%, and 7.3% (P <
0.0001) and were associated with increased odds for COPD on medications (OR 1.3) and COPD on home supplemental oxygen (OR 1.7). 1-year survival was 91%, 87%, 86%, and 80% and associated with increased risk for each COPD group (HR 1.4, HR 1.4, HR 1.9). CONCLUSION: Patients with COPD undergoing TEVAR and CEVAR have increased rates of in-hospital mortality, respiratory complications, and 1-year mortality. COPD severity is independently associated with increased respiratory complications and 1-year mortality, which should be factored into preoperative decision-making.