Ocala Regional Medical Center Ocala, FL, United States
Ramy Abdelmaseih, MD, Bilal Ashraf, MD, Randa Abdelmasih, MD, Mohammed Asimuddin Ansari, MD, Hesham Nasser, MD Ocala Regional Medical Center, Ocala, FL
Introduction: Understanding the embryological development of the arterial system and its common anatomical variations is very important not only for their surgical implications, but also in diagnosing patients with persistent symptoms despite ruling out the most frequently encountered causes. One such symptom is dysphagia caused by an aberrant right subclavian artery (ARSA) with retro-esophageal course.
Case Description/Methods: A 34-year-old female with a past medical history of gastroesophageal reflux disease presented with non-progressive dysphagia for solids, and epigastric pain. Physical examination and laboratory workup were unremarkable. Electrocardiogram (ECG) showed no ischemic changes. A barium esophagogram demonstrated an increased distal esophageal narrowing suggestive of an extrinsic compression. Esophagogastroduodenoscopy (EGD) showed normal esophageal mucosa with a pulsatile compression of the posterior portion of distal esophagus suggestive of an aberrant vessel, and healed gastric ulcers. Computed tomography angiography (CTA) scan of the chest showed ARSA with retro-esophageal course compressing the posterior portion of distal esophagus. The patient was referred to vascular surgery for operative repair. She reported complete resolution of symptoms at a 3-month follow-up.
Discussion: ARSA, commonly called arteria lusoria, is the most common intrathoracic arterial anomaly, with an incidence of 0.4-1.8%. Usually the aberrant artery follows a retro-esophageal course in 80% of the cases. Rarely, it takes a course anterior to the esophagus in 15% of the cases, or anterior to the trachea in 5% of the cases. Although mostly asymptomatic, the retro-esophageal and retro-tracheal course might result in dysphagia (71.2%), dyspnea, or unspecific retrosternal pain.
Dysphagia lusoria is a rare clinical entity with an estimated prevalence of 0.5%. It is caused by extrinsic compression of the distal esophagus by ARSA with retro-esophageal. Dysphagia becomes more pronounced when there is an additional atherosclerosis of the vessel or an aneurysmal dilation of the proximal subclavian artery –Kommerell Diverticulum– that further compresses the esophagus. Diagnostic workup include barium esophagogram, EGD, and cross-sectional imaging. Management is variable: lifestyle and dietary modification for asymptomatic patients, and surgical repair for symptomatic patients in the presence of complications (compression of adjacent structures), or that have evidence of aneurysm.
Figure: CTA chest axial views (A and B), and sagittal view (C) showing an aberrant right subclavian artery with retro-esophageal course (red arrows) resulting in distal esophageal compression (blue arrows)
Disclosures: Ramy Abdelmaseih indicated no relevant financial relationships. Bilal Ashraf indicated no relevant financial relationships. Randa Abdelmasih indicated no relevant financial relationships. Mohammed Asimuddin Ansari indicated no relevant financial relationships. Hesham Nasser indicated no relevant financial relationships.
Ramy Abdelmaseih, MD, Bilal Ashraf, MD, Randa Abdelmasih, MD, Mohammed Asimuddin Ansari, MD, Hesham Nasser, MD. P1421 - Dysphagia Lusoria: A Freak of Nature, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.