Successful Hybrid Treatment of Dysphagia Lusoria with Bypass and Endoluminal Occlusion
Victoria Konovalova, DO, Ahmed K. Ghamraoui, DO, MS, Joseph J. Ricotta, II, MD, MS, FACS.
Delray Medical Center, Delray Beach, FL, USA.
DEMOGRAPHICS:
An aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch, accounting for 17% of arch malformations, with an estimated incidence of 0.5- 1.8%. The ARSA typically arises as an abnormal fourth branch from the left side of the aortic arch and often courses posterior to the esophagus. Although asymptomatic in 90-93% of cases, it may rarely compress the esophagus and cause difficulty swallowing (dysphagia lusoria), with patients typically presenting with symptoms after age 40. This delay in symptomatology is postulated to be due to atherosclerotic changes, causing increased ARSA rigidity and tortuosity, and a reciprocal decrease in esophageal distensibility. Described herein is the rare case of a retroesophageal aberrant right subclavian artery causing dysphagia lusoria and its successful treatment.
HISTORY:
A 65-year-old female presented with a 3-year history of dry cough, difficulty swallowing and a globus sensation. She underwent multiple studies with ENT that were nondiagnostic. A CT angiogram of the chest demonstrated a congenital vascular ring with an aberrant right subclavian artery coursing posterior to the esophagus. Patient denied other symptoms. Physical exam and laboratory studies were within normal limits.
PLAN:
The patient was scheduled for an elective right carotid to right subclavian artery bypass with concomitant embolization of the aberrant right subclavian artery. Under general anesthesia, the bypass was performed first using an 8 mm Dacron graft. The right subclavian artery was selectively embolized using a 12 mm Amplatzer occlusion device that was advanced via percutaneous right common femoral artery retrograde access.
DISCUSSION:
An aberrant right subclavian artery can be of no clinical significance as most patients are asymptomatic. In the presence of symptoms, arteria lusoria requires surgical intervention. Traditionally a right posterolateral thoracotomy was required for subclavian artery reconstruction. Alternatively, a left posterolateral thoracotomy for proximal resection of the aneurysm coupled with a right supraclavicular incision for reconstruction of the subclavian artery by anastomosis to the right common carotid artery has been described. A staged approach with right carotid-subclavian bypass preceding left thoracotomy and aneurysm resection has also been described. This case report describes a combined carotid subclavian bypass with an endovascular occlusion of the origin of the aberrant subclavian artery, foregoing the need for a thoracotomy or two stage procedure.
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