A 12-day-old boy (weight: 5 lb, 4 oz) presented with severe respiratory distress. A systolic ejection murmur was heard over the pulmonary artery. A transthoracic echocardiogram showed an anomalous origin of the left pulmonary artery (LPA) (Fig. 1). Computed tomograms showed that the LPA originated from the distal right pulmonary artery (RPA) and coursed between the trachea and esophagus to the left lung hilum (Figs. 2 and 3). A 27-mm tracheal stenosis was seen in the mid-distal trachea (Fig. 4). The diagnosis was pulmonary artery sling with consequent tracheal stenosis.

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After median sternotomy, cardiopulmonary bypass (CPB) was started. We transected the LPA from its origin on the RPA and anastomosed it, end-to-side, to the left lateral aspect of the main pulmonary artery in front of the trachea. We used continuous 6-0 Prolene suture to close the stump of the RPA. We then opened the trachea anteriorly through the area of the complete tracheal rings. The mid portion of the stenotic trachea (6 rings, 15-mm length) was removed for use as an autograft. After we had anastomosed the trachea posteriorly, we trimmed the autograft patch and inserted it anteriorly to augment the tracheal lumen. The patient recovered uneventfully.

Comment

Pulmonary artery sling, a rare condition, often coexists with tracheal stenosis. Lack of clinical experience can lead to missed diagnoses and poor outcomes.¹ Echocardiography is preferred for early diagnosis because of its noninvasiveness, repeatability, and availability at the bedside. Spiral computed tomograms can display the spatial structure of pulmonary artery sling with tracheal stenosis. Concomitant tracheograms can enable the evaluation of additional zones of narrowing, which are frequently present and influence surgical treatment.

Correction can be achieved in a single surgical stage. The anastomosis to the LPA can be done unhurriedly with excellent exposure of the pulmonary artery and cardiac structures, and the use of CPB facilitates repair of the tracheal stenosis. Consistent with previous reports, we repaired our patient's tracheal stenosis by means of the tracheal autograft technique. This approach can substantially reduce postoperative ventilation time and respiratory sequelae in comparison with autologous pericardial patch tracheoplasty.^2,3 Of note, the tracheal autograft technique is typically used to treat tracheal stenosis when the stenotic segment is less than 30% of the trachea's length.