Dysphagia Lusoria: An Unusual Vascular Anomaly Diagnosed by EUS

Abstract

Dysphagia is a symptom that occurs as a result of either a mechanical obstruction or motility disorders. Dysphagia lusoria is a very rare cause of dysphagia occurring in approximately 1% of the population. It results from the impingement of the esophagus by an aberrant right subclavian artery (ARSA) coursing posterior to the esophagus. A 65-year-old female with history of hypertension, diabetes mellitus type 2, hypothyroidism, obstructive sleep apnea and osteoarthritis presented with a 2-month history of dysphagia to solids, heartburn, nausea and hoarseness. She denied weight loss, diarrhea, bleeding, chest pain, cough or toxic habits. Physical exam and laboratory tests were unremarkable. An upper endoscopy showed an extrinsic compression of the proximal esophagus at a distance of 22 cm from the incisors. The initial diagnostic impression was of a proximal esophageal subepithelial mass. She underwent endoscopic ultrasound (EUS) which revealed an extrinsic compression of the proximal esophagus caused by an artery branching off the aortic arch, likely an aberrant right subclavian artery consistent with dysphagia lusoria (Figure 1). Chest CT angiography confirmed the presence of this congenital anomaly. This case illustrates the capability of EUS for identifying this rare anatomic anomaly as the cause of a patient's dysphagia. Usually, three branches arise from the aortic arch; however, when an ARSA variant is present and it compresses the esophagus, it causes a condition called dysphagia lusoria. Interestingly, this anomaly is usually clinically silent and is identified incidentally, but a minority develops symptoms such as cough, dysphagia and thoracic pain. Patients with mild to moderate symptoms are managed conservatively with dietary modification, prokinetics and antireflux medications. Surgery is reserved for those with persistently severe symptoms. Diagnosis can be confirmed readily by CT scan, MRI or arteriography. Nevertheless, EUS has become an excellent tool to accurately identify this vascular anomaly while excluding other potential causes of extrinsic compression of the esophagus as this case shows.Figure: EUS showing extrinsic compression of the proximal esophagus caused by an artery branching off the aortic arch, likely an aberrant right subclavian artery.