Arteria subclavia derecha aberrante: a propósito de un caso pediátrico / Aberrant right subclavia artery: purpose of a pediatric case

Los anillos vasculares son anomalías anatómicas que ocurren durante el desarrollo embrionario del arco aórtico, sus ramas y de la arteria pulmonar. Estas estructuras vasculares pueden conducir a grados variables de sintomatología respiratoria y/o digestiva debido a la formación de un anillo completo o parcial que comprime la tráquea y/o el esófago. La arteria subclavia derecha aberrante es la anomalía más común del arco aórtico, con una incidencia reportada entre 0.5 a 2.5%. Generalmente es asintomática, sin embargo, la disfagia es el síntoma más frecuente porque en la mayoría de los casos transcurre detrás del esófago. El diagnóstico puede ser incidental en casos asintomáticos o como resultado del estudio de síntomas digestivos y/o respiratorios persistentes o recurrentes. Los pacientes sintomáticos requieren intervención quirúrgica. Describimos el caso de una paciente de 3 meses de edad con arteria subclavia derecha aberrante. El esofagograma mostró compresión extrínseca del esófago, y la angiotomografía computada confirmó el diagnóstico. La corrección quirúrgica se realizó exitosamente.

Vascular rings are anatomical abnormalities that occur during embryonic development of the aortic arch, its branches, and the pulmonary artery. These vascular structures can lead to variable degrees of respiratory and/or digestive symptoms by forming a complete or partial ring compressing the trachea and/or the esophagus. The aberrant right subclavian artery is the most common aortic arch anomaly, with reported incidence between 0.5 to 2.5%. It is generally asymptomatic; however, dysphagia is the most recognized symptom because in majority of the cases it crosses behind the esophagus. The diagnosis can be incidental when they are asymptomatic or as a result of the study of persistent or recurrent digestive and/or respiratory symptoms. Symptomatic patients require surgical intervention. We describe the case of a 3-month-old female patient with aberrant right subclavian artery. The barium esophagram showed extrinsic compression of the esophagus, and the computed tomography angiography confirmed the diagnosis. Surgical correction was successfully performed.

Anillos vasculares: Serie de 28 pacientes atendidos en un Servicio de Endoscopía Respiratoria Pediátrica / Vascular rings: Series of 28 patients of a Pediatrie Respiratory Endoscopy Department

Los anillos vasculares tienen una incidencia del 1 % entre las enfermedades cardiovasculares congénitas. Constituyen una malformación embriológica en la que el arco aórtico, sus ramas o las arterias pulmonares provocan presión sobre la tráquea y/o el esófago. Anatómicamente, se dividen en dos grupos, dependiendo de cómo rodean la tráquea y el esófago: completo o incompleto. La sintomatología suele iniciarse en los primeros meses de vida con estridor bifásico o espiratorio que aumenta con el llanto y la alimentación, tos traqueal de tonalidad metálica, infecciones respiratorias recurrentes, episodios de apnea refleja y cianosis, sibilancias, hiperextensión cervical, retracción esternal e intercostal, y dificultad en la alimentación. Se realizó un análisis retrospectivo de 28 pacientes con diagnóstico de anillo vascular que concurrieron a la consulta en el Servicio de Endoscopía Respiratoria del Hospital Garrahan entre enero de 2015 y septiembre de 2017.

Vascular rings account for 1 % of the congenital cardiovascular diseases. They constitute an embryological malformation in which the aortic arch, its branches, or the pulmonary arteries cause pressure on the trachea and/or oesophagus. Anatomically, they are divided into two groups -complete or incomplete- depending on how they surround the trachea and/or the oesophagus. Symptom onset is usually in the first months of life with biphasic or expiratory stridor that increases with crying and feeding, a metallic tracheal cough, recurrent respiratory infections, episodes of apnea and cyanosis, wheezing, cervical hyperextension, sternal and intercostal retraction, and feeding difficulties. A retrospective analysis of 28 patients with vascular rings seen at the Department of Respiratory Endoscopy at Garrahan Paediatric Hospital between January 2015 and September 2017 is presented.

Clinical characteristics and treatment of congenital vascular rings in 54 infants / 中华胸心血管外科杂志

Objective To summarize the clinical characteristics and therapeutic effect of congenital vascular rings in in-fants. Methods The clinical data of 54 children with vascular rings were retrospectively analyzed from August 2011 to June 2017 at our center for surgical treatment. Age 2 days to 11 months,the median age was 1 months;weight 1. 4 - 9. 4 kg,the average weight of(4. 52 ± 1. 89)kg. The type of vascular ring includes 21 cases of double aortic arch,right aortic arch with left aortic duct / ligament with or without vagal left subclavian artery in 14 cases,9 cases of pulmonary artery suture,left aortic arch with right aortic duct / ligament with or without 5 cases of oblique right subclavian artery,3 cases of nameless arterial com-pression syndrome,2 cases of other vascular rings. All cases underwent echocardiography,chest radiography,and CT scan of the heart,and 42 cases were examined before operation or intraoperative bronchoscopy. 39 cases(72％)had tracheal stenosis. Results Twenty-six patients underwent extracorporeal circulation underwent vascular anteroposterior surgery with an average extracorporeal circulation time of( 160 ± 61)min and 28 patients underwent extracorporeal circulation. Postoperative mechani-cal ventilation 1 to 22 days,the median number of days 2 days;hospitalization time 7 to 62 days,the median of 19 days,hos-pital death in 2 cases(3. 7％). Discharge patients were followed up for 2 to 74 months,respiratory symptoms to varying degrees to ease or disappear,discharged in 3 cases. Conclusion Airway stenosis is a serious complication of the vascular ring. CT is the best way to determine the vascular ring. To avoid serious airway complications,the vascular ring should be operated as soon as possible,and the airway stenosis and intracardiac malformation Children suggested concurrent treatment,this can improve the survival rate of surgery and improve the prognosis of children.

Locating ductal ligaments in vascular rings using multidetector computed tomography and magnetic resonance imaging / Localización de los ligamentos ductales en los anillos vasculares con tomografía computarizada multidetector y con imágenes de resonancia magnética

Abstract: Vascular rings are embryonic malformations of the aortic complex that encircle the trachea and the esophagus and that, occasionally, produce symptoms. Ductal ligaments (DLs) are important elements in the constitution of vascular rings. Part of the surgical treatment of symptomatic vascular rings consists in dividing the DLs. The objective of this work is to try to locate the DLs using multi detector computed tomography (MDCT) and magnetic resonance imaging (MRI) in patients with vascular rings. With this goal in mind, we reviewed 86 MRI studies and 16 MDCT studies in patients with vascular rings, with the parameters normally used in heart and large vessel studies. In 14 of the 16 MDCT cases, we were able to locate the DLs. We were unable to locate them in any of the MRI cases in the planes and sequence we used. We conclude that, although several sources of medical literature assert that DLs in vascular rings cannot be seen using any imaging procedure, it is possible to identify them using MDCT.

Resumen: Los anillos vasculares son malformaciones de origen embrionario del complejo aórtico, que rodean la tráquea y el esófago y que ocasionalmente producen síntomas. Los ligamentos ductales (LDs) son elementos importantes en la constitución de los anillos vasculares. Parte del tratamiento quirúrgico de los anillos vasculares sintomáticos consiste en seccionar los LDs. El objetivo de este trabajo es tratar de localizar los LDs con tomografía computarizada multidetector (TCMD) e imágenes de resonancia magnética (IRM) en pacientes con anillos vasculares, con los parámetros que normalmente se usan en estos procedimientos en los estudios de corazón y grandes vasos. Con este objetivo, revisamos 86 estudios realizados con IRM y 16 con TCMD de pacientes con anillos vasculares. En 14 de los 16 casos estudiados con TCMD fue posible la localización de los LDs. En ninguno de los casos estudiados con IRM, en los planos y secuencia empleados por nosotros, fue posible localizarlos. Concluimos que, aunque varias fuentes de literatura médica aseveran que los LDs en los anillos vasculares no pueden ser vistos por ningún procedimiento de imagen, su identificación es factible por medio de TCMD.

Effects of chrysin on impaired vascularendothelial function induced by high glucose / 中国药理学通报

Aim To explore the effects of chrysin on endothelial dysfunction induced by acute high glucose.Methods ① The effects of chrysin on normal isolated aortic at contraction induced by PE and on endothelial dysfunction induced by high glucose were tested in the following medium: normal group,chrysin group;normal-glucose group: glucose 11mmol·L-1 in Krebs' solution;high-glucose group: glucose 44 mmol·L-1 in Krebs' solution;mannitol group: mannitol 33 mmol·L-1 in Krebs' solution and chrysin group: 44 mmol·L-1 Glu+chrysin 1.0 μmol·L-1 in Krebs' solution.② The effects of chrysin on HUVEC cell viability after incubated in high glucose were observed in the following groups: normal-glucose group: glucose 5.5 mmol·L-1 in culture solution;high-glucose group: glucose 33.3 mmol·L-1 in culture solution;mannitol group: mannitol 27.8 mmol·L-1 in culture solution and chrysin group: chrysin(25,50 μmol·L-1)in culture solution.And the NO release was also testd in these groups.Results ① Chrysin could induce vaso-dilation in a dose-dependent manner at normal glucose.The Emax was(58.94±9.61)％,and the EC50 value was 51.9 μmol·L-1.After incubating the aortic rings with high glucose(44 mmol·L-1)for 4 h,there were significant differences in ACh-induced vascular relaxation between the normal glucose group and the high glucose group.The Emax was(32.12±3.92)％and the EC50 value was 78.0 μmol·L-1 of high glucose group(P<0.01).The endothelium-independent relaxation induced by SNP was not significantly different between the two groups.And chrysin(1.0 μmol·L-1)could reverse the decline of ACh-induced vasorelaxation response induced by high glucose(44 mmol·L-1).The Emax was(70.7±3.87)％and the EC50 value was 0.852 μmol·L-1.② The cell viability of HUVEC was depressed after incubated in high glucose,and chrysin could reverse the decline in a concentration-dependent way.And chrysin in defferent concentrations could increase the cell NO release.Conclusion Chrysin could prevent the acute high glucose-induced vascular endothelial dysfunction and could increase the NO release.

Influence of Panax quinquefolium saponins on oxidative damage and function of vascular endothelium in diabetic rats / 中国药理学通报

Aim To investigate the protective effect of Panax quinquefolium saponins (PQS ) on oxidative damage and function of vascular endothelium. Meth-ods After 3 days of adaptive feeding of Wistar male rats,56 rats were randomly selected as the control group,while others were induced by streptozotocin (STZ,30 mg·kg - 1 ). The diabetic rats were random-ly divided into three groups:the model group,PQS group(100 mg · kg - 1 )and Vitamin E group (100μmol·kg - 1 ). The normal group was injected with e-qual amount of citrate buffer. PQS and Vitamin E groups of diabetic rats were administered orally once a day. After 4,8,16 weeks of administration,the con-centration of blood glucose and LPO,SOD of serum, heart and kidney were measured,and the tension of the aortic vascular ring was determined. Results Compared with model group,with prolongation of med-ication,the concentration of glucose and the LPO of serum,heart and kidney in the PQS group significantly decreased(P < 0. 05,P < 0. 01),then the results of the aortic vascular ring tension showed that acetylcho-line induced vasodilatation and maximum diastolic per-cent were obviously elevated in PQS group(P < 0. 05, P < 0. 01). Conclusion PQS could elevate the an-tioxidant function in diabetic rats,thus improving the endothelium-dependent vasodilation function and inter-fering with the occurrence and development of diabetic vascular complications

Advances in early diagnosis and treatment of congenital vascular rings with airway stenosis / 国际儿科学杂志

Vascular ring is the congenital abnormality of the aortic arch and its branches,around the tra-chea and / or esophagus,resulting in a series of compression symptoms.The clinical prognosis depends on the degree of airway stenosis.Due to easiness to be misdiagnosed,early correct diagnosis and timely surgical treat-ment are the key to survival.This article discusses the early diagnosis and treatment progress of vascular ring with airway stenosis,aiming to improve the physician's skills of diagnosis and treatment.

Wheezing and cardiovascular abnormalities in children / 中华实用儿科临床杂志

Wheezing in children is a common problem.Approximately 30 percent of infants will have at least one wheezing episode.Although asthma is the condition most commonly associated with wheezing,the high prevalence of wheezing as a common presenting complaint requires consideration of a broad and age-dependent differential diseases.A high index of suspicion of cardiovascular anatomic anomalies should be maintained in infants and children with recurrent wheezing and minimal improvement despite reasonable treatment.Compression of the pediatric airway is a relatively common and often unrecognized complication of a variety of cardiovascular diseases.The most common congenital anomalies associated with airway compression are the vascular rings.Vascular ring abnormalities are aortic arches abnormalities,aberrant left pulmonary artery (pulmonary sling) or aberrant i nnominate artery (innominate artery syndrome).Aortic arches abnormalities include double aortic arch,right/left sided aortic arch with ligamentum arteriosum and aberrant left subclavian artery or cervical aortic arch.Other rare reasons could cause the compression of airway are absent pulmonary valve,aneurysm,left atrial enlargement or massive cardiomegaly.Imaging techniques are usually required for diagnosis.First-tier evaluation of the child with recurrent wheeze should include a chest radiograph.Echocardiography,multi detector computed tomography (MDCT) or magnetic resonance imaging (MRI) are performed as the diagnostic pathway.Bronchoscopy is currently the techniques to assess the degree of bronchial malacia and narrowing in pre-operation.Treatment of these abnormalities usually is surgical.

The value of multislice computed tomography in diagnosis of vascular rings associated with airway abnormali-ties in children / 临床儿科杂志

Objective To explore the value of multislice computed tomography (MSCT) in diagnosis of vascular rings associated airway abnormalities in children. Methods CT image data were retrospective analysis in 159 cases of vascular rings, including multiplanar reconstruction (MPR), maximum and minimum density project reconstructions. The relationship between the vascular rings and airway had been observed. Results Of 159 cases of vascular rings as-sociated with airway stenosis in 101 cases, the main airway stenosis in 79 cases, left main bronchial stenosis in 14 cas-es, right main bronchus in 8 cases, tracheal bridge in 14 cases, tracheal bronchial in 11 cases, symmetry bronchial in 2 cases. Conclusions Vascular ring often causes compression of airway narrow and dysplasia. MSCT can clearly display vascular rings and its relationship with airway, providing help for surgical and reasonable treatment.

Anillos vasculares: obstrucción de vía aérea en niños. Serie de casos / Vascular rings: airway obstruction in children. Case series

En el niño, la compresión extrínseca de la tráquea es habitualmente de origen vascular, siendo menos frecuente la ocasionada por tumores, cardiopatías, quistes y abscesos. Los anillos vasculares son anomalías congénitas del arco aórtico y sus ramas que comprimen la tráquea o el esófago en grado variable. Son poco frecuentes, pero constituyen una causa importante de difcultad respiratoria en el niño, por lo que se deben incluir en el diagnóstico diferencial de la obstrucción de la vía aérea superior. Los síntomas de presentación son el estridor, la difcultad respiratoria y la disfagia de intensidad variable. El alto grado de sospecha clínica es el factor más importante para su diagnóstico, lo contrario, puede ocasionar un significativo retraso entre el inicio de los síntomas y el diagnóstico correcto. Presentamos cuatro pacientes con diferentes tipos de anillos vasculares con el objetivo de describir manifestaciones clínicas, métodos diagnósticos y tratamiento.

In children, extrinsic compression of the trachea is usually due to vascular origin, and less frequently caused by tumors, heart diseases, cysts and abscesses. Vascular rings are congenital anomalies of the aortic arch and its branches that compress the trachea and/or esophagus to varying degrees. Although these congenital anomalies are not frequent, they constitute a major cause of respiratory distress in children. Thus, these anomalies should be included in the differential diagnosis of obstruction of the upper airway. Symptoms include stridor, respiratory distress and dysphagia of different intensity. The high degree of clinical suspicion is the most important factor for diagnosis, fail to do so can cause a signifcant delay between symptom onset and correct diagnosis. We present four patients with different types of vascular rings in order to describe clinical manifestations, diagnosis and treatment.

Anillos vasculares como diagnóstico diferencial del asma / Vascular rings in differential diagnosis of asthma

Aortic arch abnormalities and vascular rings are a rare cause of compression of trachea and esophagus causing respiratory and digestive symptoms in adults. We report a 64 years old woman with exercise induced asthma not resolving with adequate treatment. Flow/volume loop shape suggested an intrathoracic major airway obstruction. Chest X ray showed a right sided aortic notch and CT scan revealed a vascular ring composed by a right aortic arch with aberrant left subclavian artery and Kommerell's diverticulum compressing trachea and esophagus. Bronchoscopy confirmed posterior wall compression of trachea exacerbated by tachycardia as a cause of symptoms. We think that is important to consider vascular rings as a differential diagnostic entity in difficult to treat asthma.

Las anomalías del arco aórtico y sus ramas son infrecuentes. La presencia de un anillo vascular determina la aparición de sintomatología relacionada con compresión traqueal o esofágica. El diagnóstico en la edad adulta es extremadamente inusual. Se presenta el caso de una mujer de 64 años con diagnóstico de Asma inducida por ejercicio, refractaria a tratamiento, la cual presentó disnea sibilante en relación al ejercicio, que no cedió con tratamiento bien llevado. La curva flujo-volumen sugirió obstrucción variable de la vía aérea central intratorácica, la radiografía de tórax mostró botón aórtico situado a derecha, la tomografía computada del tórax demostró un anillo vascular formado por un arco aórtico derecho, con la arteria subclavia izquierda aberrante, divertículo de Kommerell comprimiendo el esófago y con la aorta descendente que en su trayecto comprime la pared posterior de la tráquea, lo que es corroborado por videobroncoscopía, describiéndose compresión pulsátil, que se exacerbaba con la taquicardia. Se concluye que la paciente tiene un anillo vascular causante de los síntomas descritos y nos orienta a establecer que en el esquema de estudio de pacientes con asma atípica o de difícil manejo, es necesario incluir las malformaciones del arco aórtico en el diagnóstico diferencial, realizando al menos radiografía de tórax y revisando atentamente la gráfica de la curva flujo-volumen.

Arco aórtico derecho circunflejo retroesofágico con ligamento arterioso izquierdo: una variedad infrecuente de anillo vascular completo / Circumflex retroesophageal right aortic arch with left arterial ligament: an infrequent variety of complete vascular ring

Los anillos vasculares pertenecen a un grupo de anomalías congénitas de los arcos aórticos en los que la tráquea y el esófago, o ambos, están completamente rodeados por estructuras vasculares. Con frecuencia pueden causar obstrucción y, en consecuencia, alteración de la deglución y dificultad respiratoria, por lo cual deben incluirse en el diagnóstico diferencial de obstrucción de la vía aérea superior. El diagnóstico temprano y la liberación quirúrgica oportuna de la obstrucción de la vía aérea y del esófago, o ambos, pueden mejorar los síntomas en la mayoría de casos. Esta afección debe sospecharse y evaluarse en lactantes o niños pequeños con síntomas respiratorios recurrentes como tos crónica, estridor y sibilancias o, lo que es menos común, con síntomas relacionados con alteración de la deglución. A continuación se ilustra el caso de un niño de seis años con problemas de deglución crónicos y desnutrición a quién se le realizó un diagnóstico incidental del arco aórtico derecho circunflejo retroesofágico con ligamento arterioso izquierdo corregido mediante cirugía.

Vascular rings are a group of congenital anomalies of the aortic arches in which the trachea and esophagus, or both, are completely surrounded by vascular structures. Often, they can cause obstruction and consequently impaired swallowing and respiratory distress, so they must be included in the differential diagnosis of obstruction of the upper airway. Early diagnosis and timely surgical release of obstruction of the airway and esophagus, or both, may improve symptoms in the majority of cases. This condition must be suspected and evaluated in infants or young children with recurrent respiratory symptoms such as chronic cough, stridor, wheezing or, less commonly, with symptoms related to impaired swallowing. We illustrate the case of a six-year-old child with chronic swallowing problems and malnutrition who underwent an incidental diagnosis of circumflex retroesophageal right aortic arch with left ligamentum arteriosum corrected by surgery.

Clinical Course of Vascular Rings and Risk Factors Associated With Mortality

BACKGROUND AND OBJECTIVES: Vascular rings refer to anomalies of the great arteries that cause respiratory or feeding problems. The purpose of this study was to analyze a series of patients with vascular rings and evaluate associated risk factors for mortality. SUBJECTS AND METHODS: A retrospective review of all patients identified with vascular rings between 1997 and 2010 in the Seoul National University Children's Hospital. RESULTS: Thirty-five patients were diagnosed with vascular rings (median age at diagnosis, 7 months). The vascular rings of 32 patients were confirmed by cardiac computed tomography or magnetic resonance imaging. The types of vascular rings were: a double aortic arch in ten patients, a right aortic arch with persistent left ligamentum arteriosum in seven, an aberrant subclavian artery in seven, a pulmonary sling in eight, and others types in three patients. Eleven patients were asymptomatic. Gastrointestinal and respiratory symptoms were seen in ten and sixteen patients, respectively. Associated cardiovascular anomalies were present in fifteen patients. Twenty patients with definite symptoms underwent surgical treatment. The median interval between diagnosis and operation was 6 days. Four patients eventually died; three deaths were associated with complex heart diseases, and one had pulmonary artery sling with severe tracheal stenosis. Only the presence of a complex heart disease significantly influenced mortality (p=0.002). CONCLUSION: Vascular rings include several types of anomalies, each with a different prognosis and symptoms. The presence of a complex heart disease was significantly associated with mortality. Early diagnosis and timely surgery in symptomatic patients are essential.

Double Pulmonary Artery Sling with Multiorgan Abnormalities / 대한흉부외과학회지

Pulmonary artery sling is a rare congenital condition in which the left pulmonary artery arises from the right pulmonary artery forming a sling around the trachea. This causes tracheal compression with the resulting respiratory symptoms. Most cases are associated with cardiovascular and tracheobronchial abnormalities. Some cases present incidentally without respiratory symptoms in adolescents and adults. We report a case with double left aberrant pulmonary artery associated with multiorgan anomalies which was incidentally found.

Surgical Correction of Complete Vascular Ring Associated with Kommerell's Diverticulum / 대한흉부외과학회지

An 11-month old girl with a feeding difficulty and recurrent aspiration pneumonia received surgical correction of complete vascular ring, which was formed by right aortic arch, aberrant left subclavian artery (LSCA) originating from Kommerell's diverticulum (KD) and ligamentum arteriosum. Through left posterolateral thoracotomy, the ligamentum arteriosum was divided to relieve the tracheo-esophageal bundle. KD was separated from the right descending aorta, and the left subclavian artery was severed from KD at its origin and trasfered to the side wall of left common carotid artery. Postoperative course was uneventful, and the patient has been followed up with a clinical improvement.

Diverticulum of Kommerell / Divertículo de Kommerell

A case of an 11-months-old girl with vomiting and laryngeal stridor is presented, and in whom a Kommerell diverticulum was demonstrated, which is a rare variant of the incomplete vascular ring. It is well known that the magnetic resonance is the best study to define this malformation. In this patient, it was the cardiac catheterization which allowed to define the structures that constituted the vascular ring. The patient was surgically treated in a successful way. The embryological knowledge of the transformations of the aortic arches offers great assistance in the understanding of all the types of vascular rings.

Se presenta el caso de lactante de 11 meses con historia de vómitos y estridor laríngeo secundaria a una rara variante de anillo vascular, divertículo de Kommerell. La resonancia magnética es considerada como el estudio ideal para definir la malformación, sin embargo, en este paciente, fue la angiografía la que permitió definir las estructuras del anillo vascular. El paciente fue tratado quirúrgicamente de manera exitosa. El conocimiento embriológico permite un adecuado entendimiento de los diferentes tipos de anillo vascular.

Aberrant Right Subclavian Artery with Dysphagia and Recurrent Pneumonia: A case report / 대한흉부외과학회지

Aberrant right subclavian artery (ARSA) is an anomaly with a reported incidence of 0.5% to 2%. Most patients with an ARSA remain asymptomatic; however about 10% of adult patients have compressive symptoms. A case is reported of a 64-year old female patient who had a few years of history of dysphagia and recurrent pneumonia. Angiography was performed, which demonstrated an ARSA with common origin of the right and left carotid arteries. Surgical correction was performed via right thoracotomy. The proximal aberrant artery was mobilized behind the esophagus. The distal, right subclavian artery was exposed, transected, and transposed with reimplantation into the aortic root by graft bypass.

A Case of Bronchial Obstruction due to Right Aortic Arch and Kommerell's Diverticulum / 소아알레르기및호흡기학회지

College of Medicine, Ulsan University, Seoul, Korea The vascular rings comprise less than 1% of congenital cardiovascular malformations and can be overlooked because they are rare diseases and show nonspecific respiratory symptoms such as wheezing or airway obstruction or apnea. This case is a 2-months old infant who had been repaired patch closure due to ventricular septal defect, but failed to wean from ventilator. Chest CT showed right main stem bronchus lying between right pulmonary arery and right descending aorta, bronchoscopy showed right main bronchus was compressed by extrinsic pulsating mass which were descending aorta and Kommerell's diverticulum . After aortopexy and transfer of subclavian artery, this patient was able to be extubated and is now free of respiratory symptoms. When there is failure to weaning of ventilator and persistent bronchial obstruction and emphysema, we should have more vigorous effort to seek the cause of bronchial obstruction, using bronchoscope and chest CT.