Indian Journal of Pediatrics, Volume 74—August, 2007768
Correspondence and Reprint requests : Dr. Vikas Kohli, MD FAAP
FACC, C-116 Sarita Vihar, New Delhi-44, Fax: 011-26941746
[Received September 11, 2006; Accepted January 25, 2007]
Innominate Artery Compression of Trachea
Manvinder Singh Sachdev, Raja Joshi, Sushma Kaul and Vikas Kohli
Department of Pediatrics, Pediatric Cardiology & Congenital Cardiac Surgery Unit, Neonatal Intensive Care Unit*,
Indraprastha Apollo Hospital, New Delhi, India
Innominate artery may cross the trachea and cause airway obstruction is a rare cause of vascular obstruction of airway. We
describe a child with stridor, inability to extubate in whom the diagnosis was suspected on fluoroscopy and confirmed by
angiography. Reimplantation of the innominate artery resulted in excellent results with longterm follow up. Variantions of this
condition and modalities for confirmation of diagnosis are discussed. [Indian J Pediatr 2007; 74 (8) : 768-769] E-mail:
Key words : Airway obstruction; Innominate artery
Vascular rings are uncommon congenital anomalies that
present with upper airway obstruction. The primary
symptomatology is related to the structures that are
encircled by the ring i.e. trachea or esophagus.
Innominate artery may cross anterior to the trachea and
compress it resulting in partial, upper airway obstruction
manifesting as stridor. This is possibly one of the less well
described types of vascular structure obstructing the
airway. The diagnostic modalities, surgical treatment as
well as outcomes are discussed.
A 2-month-old male infant presented to us with episodes
of recurrent respiratory infections and stridor since his
discharge from the nursery. On examination, his weight
was 4 Kg, and heart rate 120 per min, and respiratory rate
60-70/ min. Suprasternal retractions and subcostal
retractions were noted. No dysmoprology was noted and
an audible inspiratory stridor was noted, louder
especially when the child was active or crying. There
were no dysmorphic features and cardiovascular
examination was normal.
The chest X-ray showed mild cardiac enlargement and
normal lung fields. It was also significant for slight
The electrocardiogram (ECG) was unremarkable.
Routine blood chemistry was within normal limits.
Vascular ring or a sling was suspected.
The flourospic examination revealed a significant
tracheal tug with each systole. On lateral view
examination under fluoroscopy anterior indentation of
the trachea was suspected. Echocardiographic study
showed a left aortic arch but raised the possibility of an
abnormal first branch arising from a distal portion of the
arch. The infant was further taken up in the cardiac
catheterization laboratory and aortogram was performed
in anteroposterior projection showed the presence of left
arch and origin of innominate artery far from the left side
of trachea (Fig. 1). The lateral projection showed the
innominate artery crossing the trachea anteriorly and
compressing it. There was no patent ductus arteriosus.
With this diagnosis the child was taken up for surgery
Fig. 1. The Innominate Artery (A) is noted arising from the right of
the spine and crosses the trachea (arrow). The left carotid (B)
and subclavian (C) arteries are normal.
Innominate Artery Compression of Trachea : A Case Report and Review of Literature
Indian Journal of Pediatrics, Volume 74—August, 2007769
which confirmed the fluoroscopic and angiographic
findings. The anomalous innominate artery was
reimplanted proximally onto the arch and thereby
relieving the compression of the trachea. The child had
uneventful postoperative course without any recurrence
of symptoms and was discharged from the hospital on
the 5th postoperative day. His fluoroscopic examination
was repeated at discharge which also showed the
presence of minimal tracheal tug as compared to prior to
surgery. Predischarge echocardiographic examination
showed the reimplanted innominate arterial flow without
Innominate artery compression especially with a left
aortic arch is a rare cause of airway obstruction in infants.
It was first described by Gross and Neuhauser1 in 1948 as
consisting of cough, stridor, and occasionally apnea.
More authors reported abnormal origin and course of the
innominate artery as a cause of airway compression, with
relief of symptoms following decompressive surgery.2–4
However, others have disputed the role of the
innominate artery in causing symptoms in these children,
and believe that intrinsic abnormality of the trachea
rather than compression by the innominate artery is
responsible for the symptoms.5 Strife et al reported that
the innominate artery crosses anterior to the trachea, and
produces mild to moderate anterior indentation of
trachea in 30% of normal children without causing
symptoms.6 Mustard et al. found that only 39 out of 285
children with innominate artery compression had
symptoms marked enough to warrant surgery.7
Associated congenital abnormalities include presence of
congenital heart disease as well as esophageal atresia.
The usual symptoms reported due to innominate
artery compression are stridor, respiratory distress,
recurrent lower respiratory tract infections, and reflex
apnea. This may occur as a result of a large bolus of food
passing through the esophagus or from accumulation of
secretions in the tracheobronchial tree. The symptoms are
maximal during infancy with gradual improvement by 2
year of age as the increased cartilaginous support
strengthens the trachea and as there is cephalad
displacement of the aorta.
The diagnostic modalities include an array of
radiological tests. A lateral X-ray to begin with may show
tracheal deviation, indentation or hyperinflation. A
barium swallow may show a persistent indentation
implying a fixed obstruction. A fluoroscopic examination
may reveal a lot more than anticipated as in the index
case. Lateral fluoroscopy may show an anterior
indentation of the tracheal air column. Bronchoscopy
may show anterior tracheal compression 1–2 cm
proximal to the carina. The area of compression is
pulsatile and, when levered anteriorly by the tip of the
endoscope, leads to diminution of the corresponding
radial pulse. In the index case, bronchoscopy was
performed as an intial test and “ruled out” a vascular
ring. Aortogram may be helpful if double aortic arch is
suspected. MRI imaging has of late been used as a
modality to confirms the diagnosis. More recently, cine
MRI has been reported to be useful for dynamic imaging
of tracheal compression by the innominate artery.8
One of significant issues with multiple diagnostic
specialities being involved in a rare condition like this is
the experience, knowledge and skill of other
subspecialities which may result in falsely ruling out the
diagnosis or occasionally confirming it.9 Experience with
similar challenging cases has been reported earlier from
India10. We suggest that centres evaluate local available
skills and experience before deciding which modality
maybe most helpful in clinching the diagnosis.
1. Gross RE, Neuhauser EBD. Compression of the trachea by an
anomalous innominate artery: an operation for its relief. Am J
Dis Child 1948; 75 : 570-574.
2. 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-
3. Fearon B, Shortreed R. Tracheobronchial compression by
congenital cardiovascular anomalies in children. Ann Otol
1963; 73 : 949-969.
4. Schuster T, Hecker WC, Ring-Mrozik E, Mantel K, Vogl T.
Tracheal stenosis by innominate artery compression in infants:
surgical treatment in 35 cases. Prog Pediatr Surg 1991; 27 : 231-
5. Fletcher BD, Cohn RC. Tracheal compression and the
innominate artery: MR evaluation in infants. Radiology 1989;
170 : 103-107.
6. Strife JL, Baumel AS, Dunbar JS. Tracheal compression by the
innominate artery in infancy and childhood. Radiology 1981;
139 : 73-75.
7. Mustard WT, Bayliss CE, Fearon B, Pelton D, Trusler GA.
Tracheal compression by the innominate artery in children.
Ann Thorac Surg 1969; 8 : 312-319.
8. Faust RA, Rimell FL, Remley KB. Cine magnetic resonance
imaging for evaluation of focal tracheomalacia: innominate
artery compression syndrome. Int J Pediatr Otorhinolaryngol
2002; 65 : 27-33.
9. Brewster DC, Moncure A C, Darling RC et al. Innominate
artery lesions: problems encountered and lessons learned. J
Vasc Surg 1985 Jan;2(1) : 99-112.
10. Roy A, Kothari SS, Singh H, Sharma S. Isolation of the left
subclavian artery. Indian Heart J 2003; 55(1) : 65-67.
Erratum Download full-text
A khila K, Mahadevan S and A dhisivam B. Qualitative Evaluation of Tuberculin Test Responses in
Childhood Tuberculosis. Indian J Pediatr 2007; 74 (7) : 641-644.
Inadvertently the Figs 1 and 2 were printed in black and white whereas, these were to be printed in color.
The figures are reproduced below in color. The error is regretted.
Fig. 1. Kochs type of response
Fig. 2. Listeria type of response
770Indian Journal of Pediatrics, Volume 74—August, 2007