A 43-year-old man was admitted to the intensive care unit because of weaning impairment. His medical history revealed hypertension, marfan disease, bentall procedure, partial aortic arch replacement, and replacement of the aortic arch with bypasses to the left common carotid, proximal innominate, and left subclavian arteries. Now a thoracoabdominal aortic aneurysm (crawford extent ii) with dissection necessitated aortic replacement from the previous graft to the iliac bifurcation. Extubation attempts early after surgical intervention failed. After transfer to the intensive care unit, weaning was impaired by desaturation caused by sputum retention. Resistance during advancement of a suction tube into the trachea was noted. Bronchoscopy showed 90% stenosis caused by external compression. A computed tomographic (ct) scan (figure 1) visualized tracheal compression between the spinal column and the aneurysmatic innominate artery (maximal diameter of 3 cm). During reoperation, the innominate artery aneurysm was excluded, new bypasses to the right carotid and subclavian arteries were constructed, and fibrotic tissue compromising the patency of the trachea was transected. During the operation (positive-pressure ventilation), bronchoscopy revealed spontaneous deployment and a fully patent lumen. Five days postoperatively, bronchoscopy during spontaneous breathing (zero positive pressure) revealed tracheomalacia and a remaining stenosis of 60%. Several hours after extubation, coughing and increased inspiratory effort resulted in desaturation and stridor. Reintubation was necessary for another week. After 14 days, the patient was discharged from the hospital without stridor or dyspnea. A ct scan performed after 5 months showed persistent tracheomalacia with a diameter reduction of approximately 60% (figure 2). The patient was free of symptoms.download full-size imagefigure 1. Ct scan of the cervical region showing 90% tracheal stenosis caused by compression of the trachea between the spinal column and the aneurysmatic innominate artery (Ø 3 cm).