Footnotes Conflict of Interest Disclosure: The author has completed and submitted the Methodist DeBakey Cardiovascular Journal Conflict of Interest Statement and none were reported.

Introduction Tracheal compression by innominate artery (IA) pathology is rarely encountered, with only a few cases of IA aneurysms and congenital anomalies in the literature. We report a case of IA

ectasia and redundancy associated with a bovine trunk and exerting compression on the trachea. Case report A 70-year-old female complained Inhibitors,research,lifescience,medical of shortness of breath while lying flat and a sense of suprasternal discomfort in the upright position. There were no research apparent medical diseases (cardiac and/or respiratory) that could explain these symptoms. Examination revealed the presence of a small pulsating Inhibitors,research,lifescience,medical suprasternal lump (4 cm in diameter). The lower border of the lump was not felt, denoting that the lump arose from inside the thorax. A computed tomography scan of the neck and chest suggested an IA dilatation in close contact to the trachea (Figure 1). A diagnosis of tracheal compression

was made, and operative management to control her symptoms was decided. Figure 1 Neck computed tomography showing dilated Inhibitors,research,lifescience,medical and tortuous innominate artery slightly pushing the trachea from the left. Exploration was done through a median sternotomy. Dissection of the IA, right common carotid artery (CCA), Inhibitors,research,lifescience,medical and right subclavian artery revealed very tortuous and redundant arteries making a loop after being liberated from the surrounding tissues. The IA showed mild dilatation (2 cm in diameter). In addition, the left CCA was found arising from a

common trunk with the innominate artery (bovine trunk) (Figure 2). The trachea was partially released from compression after liberation of the looped arteries, but the junction of the left CCA to Inhibitors,research,lifescience,medical the origin of the dilated IA was still pressing on it. Figure 2 Operative view of the dilated innominate artery (IA), showing its redundancy and the elongated right common carotid and subclavian arteries. The common Resminostat origin of the left common carotid artery with IA is evident. The innominate artery was divided just distal to the left CCA origin, a 2-cm segment was excised to shorten its length, and the artery was reimplanted at a proximal site at the ascending aorta to straighten the redundant right CCA and right subclavian arteries (Figure 3). The reconstruction led to a more anatomic alignment of the vessels in the neck (Figure 4). The patient’s symptoms completely disappeared after the procedure. Figure 3 Implantation of the divided innominate artery at the ascending aorta proximal to its origin, which is now oversewn.