Innominate artery compression of the trachea in a 9-month-old previously healthy male: A case report

Introduction: Innominate Artery Compression of the Trachea (IACT) is rare but can cause stridor in infancy. IACT involves anterior compression of the trachea as the innominate (brachiocephalic) artery originates later along the transverse portion of the aortic arch. We present a case of IACT in a previously healthy 9-month-old male that failed to respond to medical therapy. This case demonstrates an unusual, delayed presentation of IACT. Case presentation: Our patient is a 9-month-old previously healthy male presenting to the outpatient pulmonology clinic with a one-month history of stridor. Patient initially presented to outside providers and prescribed systemic steroid courses, which failed to improve the stridor. On exam, patient demonstrated respiratory distress and biphasic stridor that worsened when feeding from a bottle. Patient was admitted from clinic for further evaluation by ENT. Initial chest radiographs showed findings consistent with viral lower respiratory infection versus reactive airway disease and no radiopaque foreign body. Bedside scope was performed by ENT, which did not show obstruction or foreign body above the level of the glottis. Computed tomography (CT) without contrast was performed per ENT recommendations, which showed focal tracheal narrowing but significant movement artifact. To provide further clarification on the tracheal narrowing, a direct bronchoscopy was performed by ENT, which showed tracheal compression at the level of the thoracic inlet. Computed Tomographic Angiography (CTA) of the chest confirmed the diagnosis of IACT. Patient underwent arterial relocation and reimplantation, and the tracheal compression was markedly improved on repeat bronchoscopy. Patient recovered from the procedure well with improvement in stridor and respiratory distress. Patient was discharged on POD3 and followed up in pulmonology clinic with resolution of stridor and no residual respiratory symptoms. Conclusion: This case particularly highlights the importance of continued investigation into persistent stridor that is refractory to medications, with special consideration for congenital causes.