New Onset of Dysphagia Lusoria in an Adult Diagnosed by EUS

John C. Deutsch, M.D.
John M. Steitz, M.D.
Per H. Wickstrom, M.D.

 


Keywords

EUS, Dysphagia, Dysphagia Lusoria, vascular rings.


Introduction

A 42-year-old woman presented with new onset dysphagia, weight loss, and an abnormal upper GI barium study. EUS was used as the definitive test to uncover an unusual extraesophageal finding which was responsible for her condition.


Methods for Image Cature/Processing

SVHS tapes were digitally captured using Dazzle software and processed using Adobe Premiere.

 

Disclaimer

No experimental therapies were used. All procedures were performed only after obtaining informed consent.

 

Case/Body

Figure 1

A 42-year-old woman presented with one month of solid food dysphagia. She noted solid foods sticking in her cervical esophagus, but had no problem with liquids. She had no prior history of dysphagia and denied heartburn and regurgitation. She had lost ten pounds in a month owing to poor intake.

During the physical exam, the patient appeared healthy, with no jaundice. Her neck was supple. No masseses were felt. Her heart was regular, and no vascular bruits were noted in the chest or neck.

An upper GI was performed which showed extrinsic compression of the esophagus just below the aortic arch and a filling defect posteriorly.

An EGD was performed (Video Clip 1) which revealed posterior extrinsic compression of the esophagus.

An EUS was done (Video Clip 2) to assess the extrinsic compression. An anomalous artery was seen arising off of the aortic arch and encircling the esophagus from behind.

Video Clip 3 shows the Visible Human anatomy as one goes through the esophagus starting below the aortic arch and moving proximally. As shown, there are normally no vascular structures between the esophagus and spine at the level of the aortic arch.

Video Clip 1: An EGD in the proximal esophagus, in the region seen to be abnormal on the barium esophogram.
Video Clip 2: EUS starting proximally above the aortic arch and proceeding distally through the aortic arch and then proximally again. The spine is inferior.
Video Clip 3: Visible Human anatomy as one goes through the esophagus starting below the aortic arch at the level of the carina and moving proximally.

Figures 2A-2E show images extracted from the EUS video as well as VH images to help in orientation of the videos.

Figure 2A
Figure 2B
Figure 2C
Figure 2D
Figure 2E

 

Figures 3A and 3B shows Visible Human models of the normal situation and the anatomy found in the patient.

Figure 3A
Figure 3B

MRI of the great vessels did not show any other vascular anomalies.

The patient underwent surgical correction. Briefly, the sternum was opened in the midline, and the incision
was extended a short distance into the right neck. The thymic fat on the right side was removed. The vena cava and innominate vein were freed up, as was the left carotid artery. The arch, trachea, and esophagus were dissected free and retracted anteriorly and to the left. The aberrant right subclavian artery was exposed down to its origin on the posterior, distal aortic arch. The aberrant artery was divided at its origin and the opening on the aorta oversewn. The artery was then withdrawn from behind the esophagus and attached to the right carotid artery. Figures 4A and 4B show schematic drawings of the preoperative and postoperative anatomy.

Figure 4A
Figure 4B

 

The patient tolerated the procedure well. Her symptoms have since resolved.

 

DISCUSSION


Dysphagia Lusoria is generally caused by a vascular ring consisting of an aberrant right subclavian artery which passes between the esophagus and spine (1-5). It can occur with or without other associated vascular anomalies (6,7).

Although it is a congenital anomaly, new onset symptoms in adults have been reported (3,4), though the symptoms are generally not as pronounced and precipitous as in our adult patient.

With the more widespread use of EUS, anomalous right subclavian arteries are being found incidentally (8,9). A retrospective review of 3,334 mediastinal EUS cases uncovered 12 instances in which there was an anomalous right subclavian artery, but none of these patients were symptomatic (8). However, as EUS is used as an evaluation for dysphagia and extrinsic masses, more cases should be reported.

As illustrated in this report, cases can present in unusual ways. The presentation of this case is unusual due to the rapid onset of significant symptoms in adulthood, and the diagnosis established by EUS.

Surgical repair consisting of transection and reimplantation of the anomalous artery has been reported (10). Surgical repair was curative in our patient.

 

SUMMARY

This report underscores the utility of EUS in the evaluation of extrinsic esophageal disease, and the care one should take in performing EUS of the mediastinum to ensure that these types of findings are not missed. A good sense of normal anatomy is imperative when doing EUS.

REFERENCES

1. Donnelly LF, Fleck RJ, Pacharn P, Ziegler MA, Fricke BL, Cotton RT. Aberrant subclavian arteries: cross-sectional imaging findings in infants and children referred for evaluation of extrinsic airway compression. AJR Am J Roentgenol. 2002 May;178(5):1269-74.

2. Sanger PW, Robicsek F, Daugherty HK, Bostoen H. Hysterical swallowing difficulties caused by anomalous right subclavian artery. A report of nine cases. Coll Works Cardiopulm Dis. 1967 May;13:48-543.

3. Chapunoff E, Boruchow IB. Aberrant right subclavian artery as a cause of respiratory distress and dysphagia in an adult. J Fla Med Assoc. 1985 Oct;72(10):840-2.

4. Balaji MR, Ona FV, Cheeran D, Paul G, Nanda N. Dysphagia lusoria: a case report and review of diagnosis and treatment in adults. Am J Gastroenterol. 1982 Dec;77(12):899-901.

5. Brown DL, Chapman WC, Edwards WH, Coltharp WH, Stoney WS. Dysphagia lusoria: aberrant right subclavian artery with a Kommerell's diverticulum. Am Surg. 1993 Sep;59(9):582-6.

6 . McNally PR, Rak KM. Dysphagia lusoria caused by persistent right aortic arch with aberrant left subclavian artery and diverticulum of Kommerell. Dig Dis Sci. 1992 Jan;37(1):144-9.

7. McKenna E, Kelly BE, Khan M. Dysphagia due to an aberrant left subclavian artery in a right-sided aortic arch. Ulster Med J. 2001 May;70(1):64-6.

8. De Luca L, Bergman JJ, Tytgat GN, Fockens P. EUS imaging of the arteria lusoria: case series and and review. Gastrointest Endosc. 2000 Nov;52(5):670-3.

9. Parasher VK. EUS in the diagnosis of aberrant subclavian artery.Gastrointest Endosc. 2001 Feb;53(2):244-7.

10. Mok CK, Cheung KL, Kong SM, Ong GB. Translocating the aberrant right subclavian artery in dysphagia lusoria. Br J Surg. 1979 Feb;66(2):113-6.

 




Editorial Board:
Manoop S. Bhutani, M.D.
Galveston, TX
William R. Brugge, M.D.
Boston, MA
Peter R. McNally, D.O.
Denver, CO
Iqbal S. Sandhu, M.D.
Salt Lake City, UT
Thomas J. Savides, M.D.
San Diego, CA

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