Dysphagia Lusoria: A Rare Entity and Underrecognized Cause of Dysphagia

Abstract

Abstract Management of dysphagia lusoria (DL), dysphagia caused by esophageal compression by an aberrant right subclavian artery (ARSA), is a clinical challenge. Sixty percent of patients with ARSA develop an aneurysm in the aberrant artery, which increases the risk of developing worsening dysphagia, tracheal compression, aortic dissections, and aneurysmal ruptures. Surgical management of ARSA has been studied, but no definitive standards have been established. As a result, most patients elect for surgery only when compressive symptoms become too severe. We present the case of a 68-year-old male found to have worsening dysphagia from an enlarging ARSA aneurysm. A bilateral carotid-subclavian bypass with embolization of both subclavian arteries and aortic endograft placement was performed. Despite imaging showing successful bypass of the aneurysm, the patient’s compressive symptoms worsened. The patient had a prolonged postoperative course that was complicated by pneumonia and tracheal compression, requiring stent placement. On postoperative day 45, the patient went into cardiac arrest and expired. Postmortem examination revealed an ARSA aneurysm measuring 7.8 × 4.5 × 4.3 cm. All grafts and embolization plugs were in place, without evidence of failure or migration. The aneurysmal sac contained a firm, well-organized clot, occupying 80% of the lumen. Diffuse ulcerative atherosclerotic disease was noted in the aorta. The lungs had gross and histologic findings consistent with pneumonia. Final cause of death was determined to be acute pneumonia with mass effect of the ARSA aneurysm as a contributing factor. Although the cause of the aneurysmal clot formation could not be identified, it raised the question of whether the degree of aortic atherosclerosis and aneurysmal size should be considered while developing indications for surgery. With the increased detection of ARSA, this case suggests the degree of aortic atherosclerosis and size of the aneurysm should be considered in the establishment of surgical guidelines.