A vascular cause of unexplained exertional wheeze: Keeping a high index of suspicion

A 31-year-old female was referred with a history of unexplained exertional breathlessness. The patient had normal resting lung function and a CT thorax showed no significant abnormality. Closer scrutiny of the flow-volume loop confirmed an elevated Empey's index. Cardiopulmonary exercise testing with continuous laryngoscopy was conducted to evaluate the upper airway response to exercise which confirmed loud biphasic wheeze. A bronchoscopy revealed no stenosis nor intraluminal narrowing, however, a contrast CT confirmed a right-sided aortic arch and aberrant left subclavian artery. Following multidisciplinary review, the patient opted for a surgical approach to treatment however despite initially reporting an improvement in symptoms and exercise capacity continued to suffer exertional wheeze two-years post-surgery. This clinical report describes a rare vascular cause of exertional wheeze but also provides a cautionary note in terms of providing a guarded prognosis for adults undergoing surgical intervention for tracheal compression arising from congenital vascular abnormalities.