Dysphagia lusoria: a comprehensive review

Navigating the Unexpected: Dysphagia Lusoria Complicates Severe Pneumonia With Parapneumonic Effusion

Managing pneumonia, especially when complicated by underlying anatomical anomalies, presents unique challenges that require a nuanced and multidisciplinary approach. Dysphagia lusoria, a rare vascular anomaly where the right subclavian artery originates aberrantly, can coexist with other thoracic conditions, complicating both diagnosis and treatment. Understanding the interplay between such anomalies and common infections like pneumonia is crucial for optimal patient outcomes. This case report describes a 33-year-old male with a history of recurrent pneumonia in the past who presented to the emergency department (ED) with right flank pain and dyspnea persisting for one week. Initial investigations revealed moderate parapneumonic pleural effusion and right lower lobe pneumonia. At the time, an aberrant origin of the right subclavian artery (ARSA) (dysphagia lusoria) was incidentally detected on imaging. The patient's management included antibiotic therapy tailored for pneumonia and the placement of a chest tube for pleural effusion drainage. Despite intermittent dysphagia, surgical intervention for dysphagia lusoria was deferred due to its minimal impact on daily functioning. The patient improved significantly with supportive care and antibiotics, highlighting the complexity of managing pneumonia complicated by anatomical anomalies. This case underscores the importance of multidisciplinary management and tailored treatment strategies in addressing intricate clinical scenarios.

Lusory dysphagia: Unusual cause of intermittent dysphagia

INTRODUCTION AND IMPORTANCE

Lusory dysphagia (LD) is a rare disorder resulting from extrinsic vascular compression of the esophagus, is often associated with an aberrant right subclavian artery (ARSA). LD is characterized by abnormal development of the right fourth aortic arch during embryonic stages, leading to posterior coursing of the artery in 80 % of cases. Predominantly presenting as dysphagia, LD can occasionally manifest with laryngeal stridor or dyspnea, yet it often remains asymptomatic and incidentally discovered.

CASE PRESENTATION

We present a case of LD in a 24-year-old male with Down syndrome, experiencing prolonged dysphagia and recurrent aspiration episodes. Emergency upper gastrointestinal endoscopy revealed food impactation beyond the upper esophageal sphincter, and subsequent imaging studies confirmed an aberrant right subclavian artery causing extrinsic compression.

DISCUSSION

LD is a rare condition. It is a challenging diagnosis often necessitating a combination of endoscopy, contrasted imaging and angiography. Treatment strategies vary, with conservative approaches for mild symptoms involving dietary modifications, and surgical intervention considered for persistent or severe cases.

CONCLUSION

Recognizing LD in the context of long-standing dysphagia is crucial for accurate diagnosis and appropriate management. Further research is needed to establish standardized diagnostic and therapeutic guidelines for this uncommon condition.

Buffering Mechanism in Aortic Arch Artery Formation and Congenital Heart Disease

BACKGROUND

The resiliency of embryonic development to genetic and environmental perturbations has been long appreciated; however, little is known about the mechanisms underlying the robustness of developmental processes. Aberrations resulting in neonatal lethality are exemplified by congenital heart disease arising from defective morphogenesis of pharyngeal arch arteries (PAAs) and their derivatives.

METHODS

Mouse genetics, lineage tracing, confocal microscopy, and quantitative image analyses were used to investigate mechanisms of PAA formation and repair.

RESULTS

The second heart field (SHF) gives rise to the PAA endothelium. Here, we show that the number of SHF-derived endothelial cells (ECs) is regulated by VEGFR2 (vascular endothelial growth factor receptor 2) and Tbx1. Remarkably, when the SHF-derived EC number is decreased, PAA development can be rescued by the compensatory endothelium. Blocking such compensatory response leads to embryonic demise. To determine the source of compensating ECs and mechanisms regulating their recruitment, we investigated 3-dimensional EC connectivity, EC fate, and gene expression. Our studies demonstrate that the expression of VEGFR2 by the SHF is required for the differentiation of SHF-derived cells into PAA ECs. The deletion of 1 VEGFR2 allele (VEGFR2SHF-HET) reduces SHF contribution to the PAA endothelium, while the deletion of both alleles (VEGFR2SHF-KO) abolishes it. The decrease in SHF-derived ECs in VEGFR2SHF-HET and VEGFR2SHF-KO embryos is complemented by the recruitment of ECs from the nearby veins. Compensatory ECs contribute to PAA derivatives, giving rise to the endothelium of the aortic arch and the ductus in VEGFR2SHF-KO mutants. Blocking the compensatory response in VEGFR2SHF-KO mutants results in embryonic lethality shortly after mid-gestation. The compensatory ECs are absent in Tbx1+/- embryos, a model for 22q11 deletion syndrome, leading to unpredictable arch artery morphogenesis and congenital heart disease. Tbx1 regulates the recruitment of the compensatory endothelium in an SHF-non-cell-autonomous manner.

CONCLUSIONS

Our studies uncover a novel buffering mechanism underlying the resiliency of PAA development and remodeling.

Systematic review and meta-analysis of right subclavian artery variants and their correlation with cervical-thoracic clinical conditions

BACKGROUND

A high incidence of anatomical variations in the origin of the branches of the aortic arch has been reported, Nowadays, this variation is considered the most frequent in the aortic arch, its prevalence being estimated between 0.5% and 2.5% of the population. To understand its origin, knowledge of embryonic development is necessary.

METHODS

We searched the MEDLINE, Scopus, Web of Science, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, and Latin-American literature and caribean of health sciences databases with dates ranging from their inception to June 2023. Study selection, data extraction, and methodological quality were assessed with the guaranteed tool for anatomical studies (Anatomical Quality Assurance). Finally, the pooled prevalence was estimated using a random effects model.

RESULTS

Thirty-nine studies were found that met the eligibility criteria. Twenty studies with a total of 41,178 subjects were included in the analysis. The overall prevalence of an ARSA variant was 1% (95% confidence interval = 1%-2%), the clinical findings found are that if ARSA is symptomatic it could produce changes in the hemodynamic function of the thoracocervical region in addition to other associated symptomatic complications in surrounding structures.

CONCLUSIONS

ARSA can cause several types of alterations in the cervical or thoracic region, resulting in various clinical complications, such as lusory dysphagia. Hence, knowing this variant is extremely important for surgeons, especially those who treat the cervico-thoracic region. The low prevalence of ARSA means that many professionals are completely unaware of its existence and possible course and origin. Therefore, this study provides detailed knowledge of ARSA so that professionals can make better diagnoses and treatment of ARSA.

Identification of novel buffering mechanisms in aortic arch artery development and congenital heart disease

Rationale

The resiliency of embryonic development to genetic and environmental perturbations has been long appreciated; however, little is known about the mechanisms underlying the robustness of developmental processes. Aberrations resulting in neonatal lethality are exemplified by congenital heart disease (CHD) arising from defective morphogenesis of pharyngeal arch arteries (PAA) and their derivatives.

Objective

To uncover mechanisms underlying the robustness of PAA morphogenesis.

Methods and Results

The second heart field (SHF) gives rise to the PAA endothelium. Here, we show that the number of SHF-derived ECs is regulated by VEGFR2 and Tbx1 . Remarkably, when SHF-derived EC number is decreased, PAA development can be rescued by the compensatory endothelium. Blocking such compensatory response leads to embryonic demise. To determine the source of compensating ECs and mechanisms regulating their recruitment, we investigated three-dimensional EC connectivity, EC fate, and gene expression. Our studies demonstrate that the expression of VEGFR2 by the SHF is required for the differentiation of SHF-derived cells into PAA ECs. The deletion of one VEGFR2 allele (VEGFR2 SHF-HET ) reduces SHF contribution to the PAA endothelium, while the deletion of both alleles (VEGFR2 SHF-KO ) abolishes it. The decrease in SHF-derived ECs in VEGFR2 SHF-HET and VEGFR2 SHF-KO embryos is complemented by the recruitment of ECs from the nearby veins. Compensatory ECs contribute to PAA derivatives, giving rise to the endothelium of the aortic arch and the ductus in VEGFR2 SHF-KO mutants. Blocking the compensatory response in VEGFR2 SHF-KO mutants results in embryonic lethality shortly after mid-gestation. The compensatory ECs are absent in Tbx1 +/- embryos, a model for 22q11 deletion syndrome, leading to unpredictable arch artery morphogenesis and CHD. Tbx1 regulates the recruitment of the compensatory endothelium in an SHF-non-cell-autonomous manner.

Conclusions

Our studies uncover a novel buffering mechanism underlying the resiliency of PAA development and remodeling.

Nonstandard Abbreviations and Acronyms in Alphabetical Order

CHD - congenital heart disease; ECs - endothelial cells; IAA-B - interrupted aortic arch type B; PAA - pharyngeal arch arteries; RERSA - retro-esophageal right subclavian artery; SHF - second heart field; VEGFR2 - Vascular endothelial growth factor receptor 2.

Beyond the Classic Causes of Dysphagia: Bayford-Autenrieth Dysphagia

Dysphagia lusoria (DL) is a rare clinical entity that presents with dysphagia derived from the anatomical obstruction of the esophagus by an aberrant vessel originating from the right subclavian artery. We present the case of a 64-year-old patient with a medical history of chronic, intermittent, mild, and self-limited dysphagia for over 20 years, wherein we formulated the diagnosis of DL. A 64-year-old woman arrived at the emergency department with a 24-hour history of acute progressive dysphagia, leading to intolerance to oral intake and minimal exertion dyspnea. A thorough clinical analysis and exclusion of other more common clinical entities will lead to its diagnosis. Our patient presented with respiratory symptoms, which is rare considering that these clinical presentations are more common in the pediatric population, explained by its tracheal elasticity. The combination of respiratory symptoms in an elderly patient, along with the typical mechanical dysphagia of DL, adds complexity to the diagnostic process, making this case unique.

eNOS plays essential roles in the developing heart and aorta linked to disruption of Notch signalling

eNOS (NOS3) is the enzyme that generates nitric oxide, a signalling molecule and regulator of vascular tone. Loss of eNOS function is associated with increased susceptibility to atherosclerosis, hypertension, thrombosis and stroke. Aortopathy and cardiac hypertrophy have also been found in eNOS null mice, but their aetiology is unclear. We evaluated eNOS nulls before and around birth for cardiac defects, revealing severe abnormalities in the ventricular myocardium and pharyngeal arch arteries. Moreover, in the aortic arch, there were fewer baroreceptors, which sense changes in blood pressure. Adult eNOS null survivors showed evidence of cardiac hypertrophy, aortopathy and cartilaginous metaplasia in the periductal region of the aortic arch. Notch1 and neuregulin were dysregulated in the forming pharyngeal arch arteries and ventricles, suggesting that these pathways may be relevant to the defects observed. Dysregulation of eNOS leads to embryonic and perinatal death, suggesting mutations in eNOS are candidates for causing congenital heart defects in humans. Surviving eNOS mutants have a deficiency of baroreceptors that likely contributes to high blood pressure and may have relevance to human patients who suffer from hypertension associated with aortic arch abnormalities.

Dysphagia lusoria in a young patient with a concomitant aortic arch anomaly, successfully treated with surgery: a case report

Dysphagia is a common condition in clinical practice; however, an unusual type of dysphagia due to compression of the esophagus by an abnormal right subclavian artery may be discovered in a rare subset of patients. The prognosis and treatment will depend on the severity of the symptoms and the compromise of surrounding structures. We present the case of an 18-year-old female who presented with gradually progressive dysphagia. At first, it was treated as gastroesophageal reflux disease; nonetheless, the dysphagia became severe, and after a thorough evaluation, an aberrant right subclavian artery that compressed the esophagus was discovered along with a truncus bicaroticus. She was successfully treated with surgery without any complications. On follow-ups, she's doing well.

A Simple Method to Diagnose Arteria Lusoria During Right Radial Access Coronary Intervention

Arteria lusoria (aberrant right subclavian artery) occurs in approximately 0.1-2.4 % of all individuals. The resulting tortuosity can pose a challenge for coronary angiography using radial artery access, but also can aid in the diagnosis if not already established. This case series reports three patients diagnosed with arteria lusoria by a single low-volume catheterization operator over a 6-month period, noting that its prevalence may be higher than usually reported, can be suspected when a catheter from the right radial artery crosses the midline and forms a loop as it traverses to the ascending aorta, and that it does not preclude successful catheterization and coronary intervention.

Navigating the Esophageal Enigma: A Vascular Odyssey of Dysphagia

We report a 58-year-old female with severe throat pain, difficulty swallowing, choking on solid meals, coughing, and hoarseness. CT angiography of the chest revealed vascular compression of the esophagus by an aberrant right subclavian artery (ARSA). The patient underwent thoracic endovascular aortic repair (TEVAR) and revascularization to address the ARSA. The patient experienced significant improvement in her symptoms following the surgical intervention.  Dysphagia lusoria is a rare condition involving compression of the esophagus and airway by an ARSA. While medical management is the first line of treatment for mild symptoms, surgical intervention is often necessary for severe cases or those unresponsive to conservative management. TEVAR with revascularization is a feasible and minimally invasive option for treating symptomatic non-aneurysmal ARSA, potentially resulting in favorable outcomes.

Aberrant right subclavian artery: a case of vertebrobasilar insufficiency

Aberrant right subclavian artery (ARSA) is a rare congenital malformation, wherein the aorta gives rise to the right subclavian artery as a branch off the aortic arch distal to the takeoff of the left subclavian artery. We presented a case of a patient with ARSA that manifested vertebrobasilar symptoms. PubMed search was preformed using keywords 'aberrant right subclavian artery', 'right subclavian steal' and 'vertebrobasilar', which generated nine articles. We found only seven case reports through a PubMed search that discuss ARSA in association with Subclavian steal syndrome. Approximately 71% (n = 5) of the patients in our literature review manifested with signs and symptoms of vertebrobasilar insufficiency. Given the complex anatomy in this condition, treatment should be aimed at symptom resolution. Carotid-subclavian bypass ultimately resolved the symptoms in our patient. Management in symptomatic patient is surgical. In addition to open technique, endovascular interventions can be an option.

Prevalence and Complications of Aberrant Subclavian Artery in Patients With Heritable and Nonheritable Arteriopathies

BACKGROUND

An aberrant subclavian artery (ASA) (or lusoria) is the most common congenital anomaly of the aortic arch (0.5%-2.2%; female-to-male ratio 2:1 to 3:1). ASA can become aneurysmal and result in dissection, involving Kommerell's diverticulum when present and the aorta. Data of its significance in genetic arteriopathies are not available.

OBJECTIVES

The purpose of this study was to assess the prevalence and complications of ASA in gene-positive and -negative nonatherosclerotic arteriopathies.

MATERIALS

The series includes 1,418 consecutive patients with gene-positive (n = 854) and gene-negative arteriopathies (n = 564) diagnosed as part of institutional work-up for nonatherosclerotic syndromic and nonsyndromic arteriopathies. Comprehensive evaluation includes genetic counseling, next-generation sequencing multigene testing, cardiovascular and multidisciplinary assessment, and whole-body computed tomography angiography.

RESULTS

ASA was found in 34 of 1,418 cases (2.4%), with a similar prevalence in gene-positive (n = 21 of 854, 2.5%) and gene-negative (n = 13 of 564, 2.3%) arteriopathies. Of the former 21 patients, 14 had Marfan syndrome, 5 had Loeys-Dietz syndrome, 1 had type-IV Ehlers-Danlos syndrome, and 1 had periventricular heterotopia type 1. ASA did not segregate with genetic defects. Dissection occurred in 5 of 21 patients with genetic arteriopathies (23.8%; 2 Marfan syndrome and 3 Loeys-Dietz syndrome), all with associated Kommerell's diverticulum. No dissections occurred in gene-negative patients. At baseline, none of the 5 patients with ASA dissection fulfilled criteria for elective repair according to guidelines.

CONCLUSIONS

The risk of complications of ASA is higher in patients with genetic arteriopathies and is difficult to predict. In these diseases, imaging of the supra-aortic trunks should enter baseline investigations. Determination of precise indications for repair can prevent unexpected acute events such as those described.

Clinical Characteristics and Computed Tomography Findings in Adult Patients With an Aberrant Right Subclavian Artery: A Single-Center Retrospective Cohort Study

OBJECTIVE

We sought to determine the prevalence and possible features associated with symptoms in adult patients diagnosed with an aberrant right subclavian artery (ARSA).

METHODS

In this single-center retrospective study, 386 adult patients were diagnosed with ARSA on chest CT scans performed between June 2016 and April 2021. Patients were grouped by the presence of symptoms, which included dysphagia, shortness of breath, cough, and upper airway wheezing. Four cardiothoracic radiologists reviewed the chest CT scans to assess features of ARSA. Agreement and multivariable logistic regression analyses were performed to determine interobserver variability and features associated with the presence of symptoms, respectively.

RESULTS

The prevalence of ARSA was 1.02% and 81.3% of patients were asymptomatic. Shortness of breath (74.6%) was the most common symptom. Interobserver agreement was acceptable with most variables having an interclass correlation coefficient or κ >0.80. A patient's height > 158 cm (OR: 2.50, P = 0.03), cross-sectional area > 60 mm2 of ARSA at the level of the esophagus (OR: 2.39, P = 0.046), and angle >108 degrees formed with the aortic arch (OR: 1.99, P = 0.03) were associated with the presence of symptoms on multivariable logistic regression. A distance increase per 1 mm between ARSA and trachea (OR: 0.85, P = 0.02) was associated with decreased odds of symptoms.

CONCLUSIONS

Aberrant right subclavian artery is an incidental finding in most adult patients. The cross-sectional area at the level of the esophagus, angle formed with the medial wall of the aortic arch, distance between the ARSA and the trachea, and a patient's height were features associated with the presence of symptoms.

Ortner syndrome caused by aberrant right subclavian artery: A case report

INTRODUCTION

Ortner syndrome (cardiovocal hoarseness) is characterized by recurrent laryngeal nerve paralysis secondary to a cardiovascular abnormality. Ortner syndrome caused by an aberrant right subclavian artery following a retroesophageal course without aneurysm formation is rare, with only 1 case reported in the literature. Cardiovascular abnormalities could be life-threatening and require early diagnosis and treatment. However, such abnormalities are not often considered by clinical practitioners when patients initially present with hoarseness.

PATIENT CONCERNS

A 34-year-old woman without any medical history presented to our outpatient department with hoarseness and mild dysphagia for 1 month.

DIAGNOSIS

Upon stroboscopic examination, left vocal cord incomplete paralysis was noted. Contrast-enhanced computed tomography revealed an aberrant right subclavian artery arising from the left aortic arch, causing focal compression of the esophagus and, potentially, compression of the left recurrent laryngeal nerve compression. The patient was diagnosed as left recurrent laryngeal nerve paralysis caused by an aberrant right subclavian artery following a retroesophageal course without aneurysm formation.

INTERVENTIONS

The patient was referred to a cardiovascular surgeon for resection and bypass surgery. Both the dysphagia and the hoarseness improved after the surgery.

OUTCOMES

Significant improvement of the left vocal cord paralysis and no vocal cord adduction were seen upon stroboscopic examination after 3 months. During the 5-year follow-up period, the patient remained well, and no signs of recurrence were noted.

CONCLUSION

This case can increase otolaryngologists' awareness of this etiology of hoarseness and consider it in their differential diagnosis.

The hardest pill to swallow: A freak of nature

Not required.

Dysphagia Lusoria: A Rare Cause of Adult Dysphagia

Dysphagia lusoria is an unusual condition characterized by difficulty swallowing secondary to compression of the esophagus by the aberrant right subclavian artery (ARSA). It occurs due to embryologic anomalies of the brachial arches, which are often unrecognized. Dysphagia is the prime presenting symptom in the majority, in addition to the other tracheoesophageal symptoms. Dysphagia lusoria can be diagnosed using barium swallow and chest computed tomography (CT) scan. We report a case of a young male who presented with complaints of dysphagia.

Aberrant Right Subclavian Artery Causing Dysphagia: A Case Report of Dysphagia Lusoria

Dysphagia lusoria is a rare condition, with a prevalence of less than 1%, that occurs through secondary compression of the esophagus posteriorly by an aberrant right subclavian artery. It commonly presents with dysphagia to solids. Management is usually done with dietary modification; however, more severe and intractable cases may require surgical intervention. We describe this rare vascular anomaly in a 54-year-old female presenting with mechanical dysphagia.

Evaluation of aortic arch morphologies by computed tomographic angiography in Turkish population

Background: The aim of this study was to evaluate the aortic arch morphologies in the Turkish population using the computed tomography angiography technique.

Methods: Between August 2009 and August 2019, a total of 2,037 (1,003 males, 1,034 females; mean age: 52.8±20.3 years; range, 3 months to 100 years) thoracic computed tomography angiography scans were retrospectively analyzed. The findings were classified as described previously in the literature. The prevalence of aortic arch morphologies and possible relationship with sex were analyzed. The prevalence of variations reported in previous studies was compared with the current study.

Results: The normal aortic arch pattern (type A), observed in 1,562 cases (76.7%), was determined statistically significantly more in males than females (p<0.05). The most common variation, bovine aortic arch (type B1) which observed in a total of 315 cases (15.5%), was determined statistically significantly more in females than males (p<0.05). The second most frequent variation, in which the left vertebral artery originates directly from the aortic arch (type C1) was detected in 97 cases (4.7%). There was also observed to be aberrant right subclavian artery in 21 cases (1%), right-sided aortic arch variation in seven cases (0.4%), and double aortic arch anomaly in four cases (0.1%). In terms of the reported frequency of type B variation, a significant difference was determined between the current and previous studies in Türkiye (p<0.05).

Conclusion: With the largest sample size to date, this study provides comparative information about the prevalence of aortic arch patterns in the Turkish population.

Upper Gastrointestinal Bleeding From Aberrant Right Subclavian Artery-Esophageal Fistula

Background: The most common aortic arch abnormality is an aberrant right subclavian artery (ARSA). ARSA-esophageal fistula is a rare sequela that can present with a life-threatening upper gastrointestinal (GI) bleed. Case Report: We report the case of an 88-year-old male who presented with signs of upper GI bleeding. Esophagogastroduodenoscopy demonstrated extrinsic compression of the upper third of the esophagus with ulceration. Imaging studies revealed ARSA posterior to the esophagus with pseudoaneurysm formation. These findings confirmed an upper GI bleed secondary to ARSA-esophageal fistula. The patient underwent prompt embolization of the ARSA pseudoaneurysm, followed a few days later by coil embolization of the ARSA pseudoaneurysm. Despite these interventions, the patient continued to have bleeding with anemia. He and his family opted to avoid any further interventions and instead pursued comfort care. The patient was discharged to hospice and died 3 months later. Conclusion: ARSA-esophageal fistula is a rare but potentially lethal cause of upper GI bleeding. Initial signs and symptoms can be subtle, but the presence of a GI bleed requires immediate stabilization. Surgical interventions have been shown to have longer-lasting success, but endovascular repair may be an option for patients who are deemed unfit for surgery but still require prompt stabilization. Regardless of the intervention, mortality rates for ARSA-esophageal fistula are high.

Esophageal Dysphagia in Children: State of the Art and Proposal for a Symptom-Based Diagnostic Approach

Pediatric esophageal dysphagia (PED) is an infrequent condition that can be determined by a large number of disorders. The etiologic diagnosis is challenging due to overlapping clinical phenotypes and to the absence of pediatric diagnostic guidelines. This review aims to summarize the most relevant causes of ED during childhood, highlight the clinical scenarios of PED presentation and discuss the indications of available diagnostic tools. Available information supports that PED should always be investigated as it can underlie life-threatening conditions (e.g., foreign body ingestion, mediastinal tumors), represent the complication of benign disorders (e.g., peptic stenosis) or constitute the manifestation of organic diseases (e.g., eosinophilic esophagitis, achalasia). Therefore, the diagnosis of functional PED should be made only after excluding mucosal, structural, or motility esophageal abnormalities. Several clinical features may contribute to the diagnosis of PED. Among the latter, we identified several clinical key elements, relevant complementary-symptoms and predisposing factors, and organized them in a multi-level, hierarchical, circle diagram able to guide the clinician through the diagnostic work-up of PED. The most appropriate investigational method(s) should be chosen based on the diagnostic hypothesis: esophagogastroduodenoscopy has highest diagnostic yield for mucosal disorders, barium swallow has greater sensitivity in detecting achalasia and structural abnormalities, chest CT/MR inform on the mediastinum, manometry is most sensitive in detecting motility disorders, while pH-MII measures gastroesophageal reflux. Further studies are needed to define the epidemiology of PED, determine the prevalence of individual underlying etiologies, and assess the diagnostic value of investigational methods as to develop a reliable diagnostic algorithm.

Symptomatic aberrant right subclavian artery—A case report and anesthetic implications

Vascular compression of the esophagus by an aberrant right subclavian artery (aRSA) leading to dysphagia is a rare occurrence. There has been a significant advancement in the diagnostic and surgical treatment modalities available for this disorder. Anesthetic management has evolved too and this case report highlights the anesthetic management of a 41-year-old woman presenting with symptoms of dysphagia because of compression of esophagus by an aRSA, who subsequently underwent re-implantation of aRSA into ascending aorta.

Dysphagia Lusoria: A Little Known Cause of Chest Pain

Dysphagia lusoria is a congenital abnormality characterized by an aberrant right subclavian artery. It often presents as either an incidental finding on imaging or chronic dysphagia. We describe the case of a 66-year-old female who presented with severe chest pain, worse with swallowing, along with an ongoing globus sensation. She was found to have a negative cardiac workup for ischemia with a subsequent computed tomography angiogram (CTA) of the chest showing an abnormal right subclavian artery. We emphasize the unique diagnostic approach of this rare anatomical anomaly and its potential presentation that worsens with deglutition.

Hybrid Procedure for Coexistence of Coarctation of the Aorta and Aberrant Right Subclavian Artery: A Case Report and Review of the Literature

Background: Coarctation of the aorta (CoA) can either present alone as an isolated condition or in association with other aortic arch or cardiac anomalies. One percent of patients with CoA have concomitant an aberrant right subclavian artery (ARSA). Purpose: We report the case of a 35-year-old woman with uncontrolled hypertension who was found to have CoA and ARSA. Results: The patient was treated successfully using a hybrid procedure comprising ARSA ligation and subclavian to carotid transposition, followed by thoracic endovascular aortic repair. Conclusions: Patients with CoA should be carefully studied, considering the possible coexistence of other congenital aortic arch defects, such as ARSA. Hybrid repair is a safe and effective approach for this condition.

Postoperative Dysphagia Aortica: Comparison with Other Dysphagia

Dysphagia can be classified as oropharyngeal or esophageal, and functional or structural deficits of the esophagus can cause esophageal dysphagia. Dysphagia aortica (DA) is defined as dysphagia caused by extrinsic compression of the esophagus by the aorta. The aim of this study was to investigate the characteristics of DA by comparing the findings of videofluoroscopic swallowing studies (VFSS) with those of other dysphagia. Sixty-seven patients with postoperative dysphagia aortica (PDA), dysphagia after brainstem infarction (DBI), dysphagia after anterior cervical discectomy and fusion (DACDF), and subjective swallowing difficulty (SSD) without penetration and/or aspiration, who had undergone VFSS incorporating tests using 5 ml of thin and thick liquids, were included. The clinical data were collected retrospectively. The penetration-aspiration scale, functional dysphagia scale (FDS), esophageal transit time (ETT), and aortic lesion parameters (maximal diameter and distance between the lesion and the apex of the aortic arch) were assessed. The patients with PDA had higher FDS scores than the patients with SSD and lower scores than the patients with DBI did on thin liquids, while the FDS scores on thick liquids were lower in the patients with PDA than in those with DBI or DACDF. The patients with PDA had longer ETT than the other three groups. No correlation was found between the aortic lesion parameters and the VFSS findings. Although PDA has some oropharyngeal symptoms, the esophageal phase was affected mainly by PDA. After an operation on the aorta, VFSS should be considered before resuming oral feeding.

Dysphagia lusoria: utility of high-resolution impedance manometry to identify true disease

Dysphagia lusoria is a rare cause of dysphagia due to impingement of the esophagus by an aberrant right subclavian artery. Although most remain asymptomatic, this aberrant vessel can lead to progressive dysphagia in childhood or even later in life as a result of arteriosclerotic burden and attenuation of esophageal compliance that led to esophageal compression. We present a 56-year-old man with a 3-year history of progressively worsening dysphagia to solids and liquids and globus sensation. Videofluoroscopic swallowing study (modified barium esophagram) and barium esophagram showed delayed barium tablet transit in the upper esophagus and focal smooth narrowing of the upper esophagus caused by external compression, respectively. Computed tomography imaging demonstrated external compression of proximal esophagus from an aberrant right subclavian artery with high atherosclerotic burden. In addition, high-resolution impedance manometry (HRiM) revealed a striking high-pressure pulsatile vascular band in the proximal esophagus (108 mmHg) associated with poor bolus transit, demonstrating the utility of HRiM in strengthening the diagnoses of true dysphagia lusoria.

Hybrid Treatment of Aberrant Right Subclavian Artery Causing Dysphagia Lusoria by Subclavian to Carotid Transposition and Endovascular Plug

Differences in the common aortic arch branching pattern arise from abnormal embryological development. Aberrant origin of the right subclavian artery is the most common of these anomalies. We report the case of a 47-year-old female with progressive dysphagia, found to have an aberrant right subclavian artery (ARSA) running posterior to the esophagus on computed tomography angiography. She was managed successfully with a hybrid procedure involving a right supraclavicular incision for ARSA ligation and subclavian to carotid transposition followed by endovascular closure of the ARSA origin.

Two-step treatment of dysphagia lusoria: robotic-assisted resection of aberrant right subclavian artery following aortic debranching

A 69-year-old female suffering from severe dysphagia due to an aberrant right subclavian artery was treated with a two-step approach. A right carotid-subclavian bypass was followed 2 weeks later by a robotic-assisted thoracoscopic resection of the aberrant right subclavian artery. The postoperative course was uneventful, and the patient immediately recovered from her dysphagia. In our case, the robotic-assisted technology offered major advantages and, based on our experience, may be useful in the treatment of this rare disease.

Aberrant right subclavian artery - a rare congenital anatomical variation causing dysphagia lusoria

An aberrant right subclavian artery (ARSA) is a rare anatomical variation of the aortic arch. Although an incidental finding and asymptomatic in the majority of individuals, an ARSA can cause troubling symptoms during both childhood and in later life. In adulthood, the most common symptom is dysphagia, where the condition is named dysphagia lusoria. In other rare cases it can cause shortness of breath, chronic cough and hoarseness of voice amongst others. We present a case of a 65-year-old female patient who was diagnosed with dysphagia lusoria following a barium swallow examination to investigate a 10-year history of dysphagia. She was further investigated with other imaging modalities to establish her diagnosis. The dysphagia was not progressive, nor did it result in malnutrition, and hence the patient was managed conservatively. There is currently no established guideline to classify the severity of symptoms or radiological findings of this anatomical anomaly. Our case reiterates the importance of such protocols, in order to be able to avoid the risks of an unnecessary surgical procedure, whilst being sure to prevent the undertreatment of affected individuals.

Left distal radial access in patients with arteria lusoria: insights for cerebral angiography and interventions

BACKGROUND

The transradial approach (TRA) is frequently used for neurointerventional procedures as it is safer, improves patient comfort, and decreases costs and procedural time in comparison with the transfemoral approach (TFA). Patients with arteria lusoria, or an aberrant right subclavian artery (ARSA), provide a unique challenge for cerebral angiography and interventions when using the TRA.

OBJECTIVE

To examine the hypothesis that the extreme angulation encountered while accessing the great vessels from the right TRA could be overcome by reversing the approach to the left distal TRA (dTRA).

METHODS

A prospectively maintained database of transradial neurointerventional cases since 2018 was searched. Six cases from 850 were identified, in which the left dTRA was used. Three cases were for patients with an ARSA. For the three cases of interest, patient history, pathology, imaging, and access techniques were reviewed.

RESULTS

Two diagnostic cerebral angiography cases and one intervention were successfully performed through a left dTRA.

CONCLUSIONS

Proper positioning of the left wrist and familiarity with forming the Simmons catheter can overcome this anatomical challenge. This technique and results further demonstrate that the left distal radial artery is a feasible access site for catheterization of bilateral carotid, left vertebral, and right subclavian arteries for patients with an ARSA.

Vascular pressure bands on high-resolution esophageal manometry with impedance studies

Horizontal pressure bands on high-resolution esophageal manometry with impedance (HREMI) tracings are often seen and thought to be due to cardiovascular structures compressing the esophagus. The aim of this study was to determine the prevalence and location of vascular pressure bands on HREMI studies and correlate these pressure bands to bolus clearance. HREMI studies in supine and upright positions from patients and normal volunteers were reviewed. Pressure bands were defined as bands of horizontal pressure greater than the 20 mmHg isobaric contour. Each swallow was reviewed with impedance to determine if bolus transit was impaired by the band. 38.6% of 251 patients and 36.4% of 11 normal controls had a pressure band present. There were a greater number of bands in supine versus upright position (patients: 130 vs. 25, P < 0.001 and controls: 6 vs. 1). Patients with pressure bands had similar demographics (age, gender, BMI) compared to those without. Average distal contractile integral of bands was greater in supine compared to upright (133 ± 201 vs. 60 ± 148 mmHg cm s, P < 0.05). Bands were commonly located clustered at 46 and 72% of esophageal length. Bolus transit was impaired by bands in 20.4% of supine and 14.0% of upright swallows. Vascular pressure bands can have a prominent appearance on HREMI studies, present in, being more prevalent and having greater pressure in the supine than the upright position. These vascular bands, when present, may impair esophageal transit.

[The Treatment of Aneurysms of the Extremities Arteries - a Systematic Overview - New Therapies for Isolated Iliac Artery Aneurysm Employing a New Classification]

Aneurysms of arteries in the extremities have a low incidence and are often manifest through complications. The most serious complications are rupture and extremity-threatening ischemia. Both usually lead to the diagnosis. Absolute indications for therapy are symptomatic aneurysms and asymptomatic aneurysms of 2 cm diameter or more. The extrailiacal gold standard is interponat or bypass with venous graft material. Endovascular methods are reserved for inoperable patients and clinical decisions on special cases. In contrast, complex endovascular techniques have been established in isolated iliac aneurysms and have significantly improved treatment options. Their implementation is bound to the existence of a suitable landing zone. This is the basis for a new classification of isolated iliac artery aneurysm. With the help of morphological subtypes, this classification permits standardised procedure planning for perfusion preservation of the internal iliac artery. The present article gives an overview of the current treatment strategy for aneurysms of extremities arteries. Similarities and regional differences in therapy are discussed.

Incidental finding of an aberrant left pulmonary artery, an aberrant right subclavian artery, and a tracheal bronchus in an adult woman with a meningioma and a history of medulloblastoma

The aberrant left pulmonary artery and the aberrant right subclavian artery are rare congenital vascular anomalies, and the tracheal bronchus is a rare congenital respiratory anomaly. A 33-year-old female patient, with a history of desmoplastic medulloblastoma, was surgically treated at our hospital for a meningioma. On the second postoperative day, the patient complained of shortness of breath and chest pain. Contrast-enhanced multislice computed tomography was negative for pulmonary embolism, but incidentally revealed all three congenital anomalies. In our report, we detail this exceedingly rare case.

Co-Occurrence of Rarest Type of Dysphagia Lusoria (Type N-1) and Eosinophilic Esophagitis in a Cognitively Disabled Individual

Dysphagia is an expressive symptom, described by an individual as “difficulty in swallowing.” Dysphagia due to esophageal compression from an aberrant right subclavian artery is rare, and it is termed as “dysphagia lusoria.” We present a rare case of co-occurrence of dysphagia lusoria with esophageal eosinophilia in a patient with cognitive disability which portends a case with diagnostic challenge and treatment dilemma. A 31-year-old man with intellectual disability, cerebral palsy, previous history of feeding difficulty, and esophageal food impaction presented with esophageal foreign body impaction. He has no known history of atopy and food allergies. There was no laboratory evidence of peripheral eosinophilia. The IgE-mediated allergic test was unremarkable. His prior presentation revealed a diagnosis of eosinophilic esophagitis. The imaging studies showed proximal esophageal dilatation with extrinsic compression at the level of the upper esophagus. The foreign bodies were removed successfully through the help of upper endoscopy. Subsequent evaluation revealed a rare type of dysphagia lusoria (type N-1) due to an aberrant left subclavian artery arising from the right-sided aortic arch. The patient's family refused further management of artery lusoria. Prolonged stasis of secretions and food in the esophagus can also lead to increased esophageal eosinophils. In our case, it remains undetermined whether increased number of esophageal eosinophils resulted from primary eosinophilic esophagitis or due to prolonged food stasis from esophageal compression caused by an aberrant subclavian artery. However, food impaction right above the compression site makes dysphagia lusoria the likely etiology.

Dysphagia lusoria: problem or incidentaloma?

PURPOSE OF REVIEW

To address the incidental versus pathogenic nature of dysphagia lusoria and to provide a review of the cause, clinical presentation, diagnosis, and treatment of this condition with respect to recent literature.

RECENT FINDINGS

Case reports comprise the majority of recent literature concerning dysphagia lusoria. Many patients with an aberrant right subclavian artery (ARSA) have additional coexisting vascular anomalies. While most individuals present around age 50, some present as children and neonates. Of note, this population may present with dysphagia as opposed to respiratory findings alone, as previously described. In the diagnostic workup, most patients receive a battery of radiologic tests, which may not be necessary. Significantly, dietary modifications and medical management alone may resolve symptoms. Nonetheless, a wide range of operative techniques are available for the treatment of dysphagia lusoria.

SUMMARY

Clinicians should have a higher suspicion for dysphagia lusoria in patients with known vascular, heart, or chromosomal anomalies. Diagnosis should begin with a barium esophagram followed by a computed tomography angiogram or magnetic resonance angiogram. Avoid unnecessary studies. In many cases, an ARSA may be an incidental finding with comorbid gastroesophageal reflux disease or another medical condition responsible for the symptoms. Medical versus surgical management should be considered on a case-by-case basis.

Prevalence and Anatomy of Aberrant Right Subclavian Artery Evaluated by Computed Tomographic Angiography at a Single Institution in Korea

Objective

Aberrant right subclavian artery (ARSA) is a rare anatomical variant of the origin of the right subclavian artery. ARSA is defined as the right subclavian artery originating as the final branch of the aortic arch. The purpose of this study is to determine the prevalence and the anatomy of ARSA evaluated with computed tomography (CT) angiography.

Methods

CT angiography was performed in 3460 patients between March 1, 2014 and November 30, 2015 and the results were analyzed. The origin of the ARSA, course of the vessel, possible inadvertent ARSA puncture site during subclavian vein catheterization, Kommerell diverticula, and associated vascular anomalies were evaluated. We used the literature to review the clinical importance of ARSA.

Results

Seventeen in 3460 patients had ARSA. All ARSAs in 17 patients originated from the posterior aspect of the aortic arch and traveled along a retroesophageal course to the right thoracic outlet. All 17 ARSAs were located in the anterior portion from first to fourth thoracic vertebral bodies and were located near the right subclavian vein at the medial third of the clavicle. Only one of 17 patients presented with dysphagia.

Conclusion

It is important to be aware ARSA before surgical approaches to upper thoracic vertebrae in order to avoid complications and effect proper treatment. In patients with a known ARSA, a right transradial approach for aortography or cerebral angiography should be changed to a left radial artery or transfemoral approach.

CT evaluation of aberrant right subclavian artery: anatomy and clinical implications

PurposeThe aim of the study was to perform CT angiography-based evaluation of aberrant right subclavian artery prevalence, anatomy, and its influence on clinical symptoms.

METHODS

A total of 6833 patients who underwent 64-slice or dual-source CT angiography and those who revealed aberrant right subclavian artery underwent evaluation of its anatomy and were interviewed for the presence of clinical symptoms.

RESULTS

Aberrant right subclavian artery was found in 32 (0.47%) patients consisting of 13 males and 19 females, with mean age of 60.8±13.4 years. Among the interviewed 30 (94%) patients, oesophageal compression was observed in 14 cases (47%) and tracheal compression in three cases (10%). None of the patients underwent surgery related to aberrant right subclavian artery. Dysphagia was the most common clinical symptom in nine cases (30%), and in those patients the median distance between aberrant right subclavian artery and trachea was lower (4 mm) than in individuals without dysphagia (7.5 mm) (p = 0.009). The median lumen area of the aberrant right subclavian artery at the level of oesophagus was higher in patients with dysphagia (208 mm2) compared with individuals without dysphagia (108 mm2) (p = 0.01).

CONCLUSIONS

Aberrant right subclavian artery is a rare occurring abnormality in CT angiography. In the evaluated adult population, the most common symptom was dysphagia, which occurred in patients with decreased distance between aberrant right subclavian artery and trachea and increased lumen area of the aberrant artery at the level of compressed oesophagus.

Identification of clinical parameters to increase the diagnostic yield of the non-emergent upper gastrointestinal series in pediatric outpatients

BACKGROUND

Outpatient, non-emergent upper gastrointestinal (GI) series are frequently requested in children with no surgical history who have nonspecific symptoms such as abdominal pain, failure to thrive and vomiting. The positive yield of an upper GI series in these patients, and, thus, its utility, has not been studied.

OBJECTIVES

We evaluated the incidence of positive upper GI findings in children without a history of GI pathology or abdominal surgery in order to identify clinical indications associated with a greater diagnostic yield.

MATERIALS AND METHODS

Findings of upper GI series performed between October 2015 and October 2017 in three institutions in children younger than 18 years of age were retrospectively reviewed. The upper GI series protocol for each institution was also reviewed. Children with a medical or surgical GI history, children with insufficient history in the chart and those with an incomplete upper GI series were excluded from the study. Exam indications, patient demographics and clinical history were obtained from the electronic medical records.

RESULTS

Of 1,267 children who underwent outpatient upper GI series, 720 (median age: 2 years) had no GI history and were included in the study. The most common indications were non-bilious vomiting (62%), reflux symptoms (28%) and abdominal pain (20%). Upper GI series were normal in 605/720 cases (84%), including 25/26 children with reported bilious emesis. Of the 115 positive studies, 78 (68%) showed only gastroesophageal reflux (GER) (median age: 11 months). Of the remaining 37 studies, 19 demonstrated esophageal findings. One case of malrotation without midgut volvulus was identified in a patient who presented with dysphagia and reflux symptoms. Using a multinomial logistic regression model and adjusting for other variables, reflux symptoms and younger patient age were independent predictors of GER on upper GI series (relative risk ratios of 2.2 and 0.9, respectively). Dysphagia and/or foreign body sensation and older patient age were independent predictors of the presence of esophageal findings (relative risk ratios of 3.3 and 1.1, respectively).

CONCLUSION

The yield of routine upper GI series in children with nonspecific symptoms, such as abdominal pain and vomiting, and no surgical history is low. Diagnostic yield was improved in older children and in those complaining of dysphagia and/or foreign body sensation. Routine upper GI series should be avoided in clinically well children with symptoms only of uncomplicated GER and no significant GI history. In children with a history of dysphagia and/or foreign body sensation, an esophagram/barium swallow can suffice.

The Natural and Unnatural History of Congenital Aortic Arch Abnormalities Evaluated in an Adult Survival Cohort

BACKGROUND

This study describes the different types of congenital vascular rings according to their anatomy, symptoms, and age at clinical onset and reports the surgical outcomes.

METHODS

A retrospective observational database study was conducted, reviewing the medical charts of 69 adult survivors with a history of a vascular ring, identified from the Dutch Congenital Cor vitia database.

RESULTS

Median age at presentation was 8.5 years (0-53.0 years). Thirty patients (43.5%) had a "left aortic arch with aberrant right subclavian artery," 21 patients (30.4%) a "double aortic arch," and 16 patients (23.2%) a "right aortic arch with aberrant left subclavian artery." The main symptomatology at presentation comprised respiratory symptoms (82.9%). Almost three-quarters of patients were also diagnosed with asthma/bronchial hyperreactivity. Patients with a double aortic arch had more symptoms than patients with a left aortic arch with aberrant right subclavian artery and right aortic arch with aberrant left subclavian artery (P < 0.001), requiring surgery most often (P < 0.001). In patients with childhood onset of symptoms, preoperative spirometry (ie, peak expiratory flows) was more often abnormal as compared with adult patients (P = 0.007). Surgery was performed in 42.0% of all patients at a median age of 17 years (0-63.0 years). Twenty-four (92.3%) of the operated patients showed improvement or complete relief of symptoms shortly after surgery. Of 26 asymptomatic nonoperated patients, 3 patients (11.5%) eventually developed symptoms.

CONCLUSIONS

The low incidence of vascular rings, their anatomic heterogeneity, and a wide range of common symptoms often lead to misdiagnosis. Clinical awareness is warranted as a large subset of patients could benefit from surgery, even at an adult age.

Foreign body sensation: A rare case of dysphagia lusoria in a healthy female

Dysphagia lusoria is a rare disease due to an aberrant right subclavian artery that passes posteriorly between the esophagus and the spine. David Bayford coined the term itself meaning "freak or jest of nature" in 1761 describing a case in which the patient had long term dysphagia that eventually led to death. Most cases of dysphagia are due to an aberrant right subclavian artery running posterior to and causing esophageal compression, but only 20-40% of aberrant arteries actually lead to trachea-esophageal symptoms, including dysphagia. The majority of patients with an aberrant right subclavian artery are asymptomatic. Treatment for dysphagia lusoria varies depending on the severity of the symptoms. Dietary modifications are recommended in patients with mild to moderate symptoms while vascular reconstruction is necessary for patients with severe symptoms. We present a 44-year-old female who was diagnosed with dysphagia lusoria due to a right-sided aortic arch and aberrant left subclavian artery (ALSA) with aneurysmal dilation. Right aortic arch with ALSA is an uncommon arch anomaly, and only occurs in about 0.05% of the population. Prior case reports of dysphagia lusoria differ in that they did not report patients with an uncommon presentation of dysphagia lusoria with aneurysmal dilatation nor was the patient diagnosed in the emergency department.