Innominate Artery Compression of the Trachea in Infants with Stridor and Apnea

Compression of an infant's trachea by the innominate artery (Fig. 1) may cause stridor, cyanosis, apnea, and even death. This was recognized by Gross and Neuhauser (3) in 1948 when they reported surgical relief of these symptoms by suturing the “anomalous” artery to the sternum. The “anomaly” drew virtually no attention in the next decade until the report of Fearon and Shortreed in Toronto (1). They diagnosed such compression on the basis of endoscopic findings in more than 300 infants and children. More than 10 per cent of the patients had enough respiratory problems in addition to stridor to require surgery (1, 2). Angiographic findings were shown by Maurseth (7) in 1965. He also noted that the symptoms disappeared with increasing age in cases in which no operation was performed. This report will emphasize a simple plain film technic that has allowed this diagnosis to be made in 5 cases, all confirmed by angiography. Since not all patients needed surgery and not all patients operated on benefited from surgical treatment, criteria for operation will be proposed. A. Dramatic Relief by Surgery Case I: A. K., born on Nov. 16, 1965, was a full-term male infant in whom stridor developed on Dec. 22. A brassy cough (and stridor) led to the first hospitalization at five weeks of age. After four days in the hospital the patient left only to be almost immediately readmitted with cyanosis during crying. Subcostal retractions were noted, and laryngoscopy revealed a good subglottic airway. The diagnosis of “congenital laryngeal stridor” and “croup” was made. Sent home, the child had to be readmitted for the third time for cyanotic spells with the new development of left upper lobe pneumonia. A barium esophagram failed to show any posterior esophageal compression or a “vascular ring,” but it was noted that many lateral chest films had shown a constant curvilinear anterior tracheal indentation (Fig. 2). The diagnosis of an anterior vascular compression of the trachea was suggested, and a right brachial arteriogram showed the innominate artery to arise far to the left of the midline, crossing the trachea on the frontal angiogram (Fig. 3). No lateral studies were undertaken. Because of the alarming clinical picture, thoracotomy was performed. The trachea was found to be tightly compressed by the innominate artery. The latter was attached by adventitial sutures to the manubrium with an immediate and lasting striking relief of respiratory symptoms. Repeat lateral chest films showed a normal tracheal air column (Fig. 4). Case II: E. D., born on June 18, 1967, was a full-term female infant in whom respiratory distress after feeding developed at five weeks of age. She had been hospitalized elsewhere at seven weeks of age, at which time her chest film with barium swallow was normal.