1820 Dysphagia Lusoria: When Surgery Is the Bitter Pill to Swallow

Abstract

INTRODUCTION: Aberrant subclavian artery (ASA) is a rare anatomic variant and frequently asymptomaticcondition. We present a case of a young patient with progressive dysphagia who underwent extensive workup and repetitive endoscopic procedures until diagnosed. CASE DESCRIPTION/METHODS: 35-year-old female with history of systemic lupus erythematous, presented with progressive dysphagia for several weeks. No preceding trauma, procedures or infections. She had anunremarkable upper endoscopy, but an empiric esophageal dilation was performed. However, in few months her symptoms recurred; another dilation was pursued along with proton pump inhibitor therapy and dietary changes. Three years later, she had worsening dysphagia, leading to an 8-pound weight loss. An esophagram raised suspicion for an extrinsic esophageal compression (Figure 1). A computed tomography (CT) angiogram confirmed the presence of a right ASA (Figure 2). Patient was referred to thoracic surgery and underwent operative repair of right ASA (Figure 3). A repeated esophagram on the 5th day after surgery, showing no delay in the passage of the barium pill. Upon discharge, she was tolerating soft diet and in one month she was able to eat normally. DISCUSSION: ASA is characterized by a vascular ring structure due to aberrant arising of one of the subclavian arteries (arteria lusoria) from the aortic arch. Although ASA is the most common congenital aortic arch anomaly, it occurs in less than 2.5% of overall population. Its management depends on symptoms: if mild and intermittent, dietary and behavioral modifications are appropriate; if severe dysphagia, surgery should be considered. During adulthood, 30% of patients are symptomatic with intermittent dysphagia being the most prominent symptom. Late presentation is probably related with atherosclerosis and aneurismal formation due to advancing age. Even though ASA is found mostly in women and its possible relation with atherosclerosis, we could not find any data in literature linking ASA to SLE. Dysphagia lusoria can be easily diagnosed by barium esophagogram, an inexpensive test which would typically show an impression defect at the level of the third or fourth vertebra. Esophageal manometry and upper endoscopy usually are unrevealing but a CT angiogram can confirm the diagnosis. Because of its rarity, ASA is not commonly suspected upon evaluation of dysphagia in adults, often times causing recurrent endoscopies and other non-revealing tests to be repeated.