Asian Cardiovasc Thorac Ann 2000;8:391-393
© 2000 Asia Publishing EXchange Pte Ltd
Innominate Artery Compression of Trachea: Treatable Airway Obstruction
Sachin Talwar, MS,
Rajesh Sharma, MCh,
Sandeep Agarwal, MCh,
Sanjeev Sharma, MD,
Anil Bhan, MCh,
Usha Kiran, MD,
Panangipalli Venugopal, MCh
Department of Cardiothoracic and Vascular Surgery
Cardiothoracic Sciences Centre
All India Institute of Medical Sciences
New Delhi, India
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For reprint information contact: Rajesh Sharma, MCh Tel: 91 11 686 4851 Fax: 91 11 686 2663 email: rsharmacvs{at}hotmail.com Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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Abstract
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A case of innominate artery compression of the trachea is reported for its rarity. The features of this condition are briefly described.
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Introduction
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Innominate artery compression of the trachea is an uncommon form of airway obstruction that produces stridor, cyanosis, and respiratory arrest.1 If diagnosed and treated in time, the results can be gratifying. We describe one such case and briefly review the treatment options.
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Case Report
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A 10-week-old boy weighing 6 kg underwent a Senning operation for ventriculoarterial discordance with dextro-position of the aorta and intact ventricular septum. His postoperative course was uneventful and he was dis-charged on the 12th postoperative day. At 5 months of age, he developed tachypnea and congestive cardiac failure due to obstruction of the pulmonary venous chamber, for which he underwent pericardial patch augmentation. Postoperatively, the baby required prolonged mechanical ventilatory support and was intubated for 7 days. On extubation, he developed stridor and occasional cyanotic spells unresponsive to steroids and antibiotics. The stridor was inspiratory and increased on excessive crying and on feeding; it was associated with elevation of systemic arterial pressure. His echocardiogram was normal. The clinical picture suggested respiratory obstruction due to subglottic stenosis as a result of prolonged endotracheal intubation, or vascular rings producing tracheal com-pression, or an intrinsic airway abnormality (tracheo-malacia). A plain chest radiograph was unhelpful. Contrast-enhanced computed tomography of the chest indicated tracheal compression approximately 1 to 2 cm above the carina by a vascular dilated structure, probably the right innominate artery (Figure 1
). As the child had elevated systemic arterial pressure, he was started on captopril, his stridor improved, and he was sent home.
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Figure 1. Transaxial computed tomography image shows an extrinsic arterial compression of the trachea by the innominate artery (arrow).
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At 10 months of age, he presented again with increased stridor. Repeat contrast-enhanced computed tomography revealed the same findings, suggesting innominate artery compression of the trachea. Magnetic resonance imaging was equivocal. On tracheobronchoscopy, the bronchoscope passed easily through the trachea. There was no intrinsic lesion in the airway. On withdrawal of the bronchoscope, a tubular pulsatile indentation was visible in the wall of the trachea 1 to 2 cm above the carina. The indentation extended anteriorly from the distal left to the proximal right side. These findings suggested innominate artery compression of the trachea, hence surgery was undertaken. After a midsternotomy and freeing of adhesions, the dilated right innominate artery was seen to be coursing anterior to the trachea and producing tracheal compression on its right anterior aspect (Figure 2A). There was softening of the trachea at the site of compression. The innominate artery was encircled at its origin and mobilized to its bifurcation. Heparin was administered intravenously in a dose of 1 mg•kg–1. The artery was clamped 2 cm from its origin and a second clamp was placed at its origin from the aorta. The innominate artery was excised from the aorta and the resulting aortotomy was closed with a double row of a 6/0 polypropylene sutures. A new site for the origin of the innominate artery was chosen on the greater curvature of the ascending aorta, completely to the right of the trachea. After application of a longitudinal clamp at this site, an aortotomy was made and the innominate artery was anastomosed directly to the aorta using continuous 6/0 polypropylene suture. The completed repair is shown in Figure 2B. Postoperative recovery was uneventful and the baby was extubated 36 hours after surgery. One month later, he was free of stridor and healthy.
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Figure 2. (A) Right innominate artery (I) coursing anterior and to the right of the trachea (T) and producing tracheal compression. (B) Operative repair: the innominate artery has been implanted lower down so that its new origin is completely away and to the right of the trachea. Hatched area is the area of tracheal softening due to the compression.
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Discussion
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Innominate artery compression of the trachea was described in 1948 by Gross and Neuhauser2 as an uncommon form of airway obstruction. Although there has been controversy regarding its clinical significance, some infants clearly have episodes of severe stridor, cyanosis, and respiratory arrest referred to as "dying spells".1–4 Other features include apneic episodes, repeated bronchopulmonary infections, and exercise-induced stridor. Stridor associated with this condition is usually not present at birth and most infants present after 3 months of age, usually between 3 and 10 months. Symptoms are uncommon after 2 years of age.3 After this age, mild degrees of tracheal compression resolve with increased growth and cartilaginous support of the trachea. Also, with increasing age, the aortic arch grows and there is cephalad displacement of the origin of the innominate artery, which makes compression rare.4,5 For diagnosis of this condition, bronchoscopy is best and typically shows an oblique narrowing 1 to 2 cm above the carina. At least 50% to 75% narrowing of the tracheal lumen is necessary for diagnosis. Magnetic resonance imaging is regarded as the radiographic investigation of choice, it excludes vascular rings, mediastinal tumors, and intrinsic airway abnormalities.1,4,6 However, it was not helpful in this patient.
Once diagnosed, the indications for surgical treatment need to be defined. Surgery is clearly indicated in patients with severe stridor unresponsive to conservative treatment such as steroids and antibiotics, or if there are two or more episodes of bronchopneumonia or tracheobronchitis. Relative indications are mild degrees of compression in patients with tracheomalacia, laryngomalacia, or asthma because the airway is further compromised.6 Pure radiographic evidence of innominate artery compression of the trachea is not an indication for operation in the absence of significant symptoms because as many as 30% of normal children have anterior indentation of trachea on lateral chest radiographs.3 Surgical options consist of innominate artery suspension (aortopexy), reimplantation lower down the aortic arch, or transsternal suspension by pericardial "hammock".1,4,7 In aortopexy, the aorta is suspended to the undersurface of the sternum by a row of braided Dacron sutures so that the aorta is lifted anteriorly in the chest and the innominate artery is lifted off the anterior tracheal wall. Although good results have been reported, recurrence requiring reoperation may occur in up to 10% of patients, and no relief in up to 15%.1,8 Suspension of the innominate artery using a pericardial "hammock" has not been widely used and long-term results are unclear.7 Reimplantation of the innominate artery, as described in this case, has been reported to be safe and effective with no recurrence.4 However, there is a risk of intraoperative or postoperative stroke, bleeding, and late development of stenosis at the anastomotic site.4 Innominate artery compression of the trachea is a potentially curable cause of extrinsic airway compression but the diagnosis can be made only if a high index of suspicion is entertained.
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References
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Jones DT, Jonas R, Healy GB. Innominate artery compression of the trachea in infants. Ann Otol Laryngol 1994;103:347–50.
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Gross RE, Neuhauser EB. Compression of the trachea by an anomalous innominate artery: an operation for its relief. Am J Dis Child 1948;75:570–4.[Abstract/Free Full Text]
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Strife JL, Baumel AS, Dunbar JS. Tracheal compression by the innominate artery in infancy and childhood. Radiology 1981;139:73–5.[Abstract/Free Full Text]
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Hawkins JA, Bailey WW, Clark SM. Innominate artery compression of the trachea: treatment by reimplantation of the innominate artery. J Thorac Cardiovasc Surg 1992;103:678–82.[Abstract]
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Fearon B, Shortreed R. Tracheobronchial compression by congenital cardiovascular anomalies in children. Ann Otol 1963;72:949–69.
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Meyer CM, Wiatrak DJ, Cotton RT, Bore KE, Bailey WW. Innominate artery compression of the trachea: current concepts. Laryngoscope 1989;99:1030–4.[Medline]
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Chahidi N, Casimir G, DeManet H, Cavenaille JC, Goldstein JP, Deuvaert FE. Innominate artery compression of the trachea: trans-sternal suspension by a pericardial "hammock". Acta Chir Belg 1995,93:35–78.
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Moes CAF, Izukawa T, Trussler GA. Innominate artery compression of the trachea. Arch Otolaryngol 1975; 101:733–8.[Abstract/Free Full Text]
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Abstract
Introduction
