Dysphagia lusoria

Clinical History

An 80-year-old man with known history of systemic hypertension and old cerebrovascular accident presented with a 6-month history of intermittent dysphagia with infrequent nausea and vomiting without a known cause and was transferred to our department for radiological assessment.

Imaging Findings

Contrast-enhanced CT of the thorax reveals an apparent right subclavian artery with a retroesophageal course and extrinsic compression on the posterior oesophageal wall. The artery shows signs of atherosclerosis (Fig. 1, 2).

Discussion

Dysphagia lusoria is the term used to describe the swallowing difficulties resulting from oesophageal compression by an aberrant right subclavian artery (arteria lusoria).
The first case of a symptomatic aberrant right subclavian artery was described by Hunauld in 1735 [1].
Aberrant right subclavian artery (ARSA) is the most common congenital abnormality of the aortic arch, which occurs in 0.5% to 1.7% of the population [2].
The congenital abnormality of the right subclavian artery can be explained by the involution of the 4th vascular arch with the right dorsal aorta. The 7th intersegmental artery remains attached to the descending aorta, and the latter becomes the right subclavian artery [3].
The artery crosses between the oesophagus and the vertebral column to reach the right arm in 80% of cases. In 15% of individuals, it runs between the oesophagus and the trachea and passes anterior to both in about 5% of cases [4].
About two thirds of cases with this congenital anomaly experience no symptoms. In symptomatic adults, complications such as dysphagia, chest pain, intermittent dyspnoea, chronic cough, aortitis and ruptured associated aneurysm have been reported [5].
Dysphagia is reported in 90% of the symptomatic patients and is commonly found in older patients, which is explained by increased rigidity of the oesophageal wall, elongation of the aorta and arterial atherosclerosis [5].
In children, respiratory symptoms such as stridor and recurrent chest infections due to compression of trachea are reported more frequent than dysphagia, mainly due to their soft trachea comparing with adults [6].
The diagnosis of dysphagia lusoria is difficult as the clinical presentations are mostly nonspecific and endoscopic examinations can be negative in more than 50% of the patients [5].
The morbidity and mortality rates are higher if there is an associated dilatation in the proximal ARSA “diverticulum of Kommerell” [7].
Barium study may show posterior indentation on the oesophagus. Enlarged superior mediastinum can be the only radiological finding on chest radiography. Angio-CT and MRI of the thorax are the best diagnostic modalities for ARSA, but angiogram may be required for preoperative assessment [8].
Management of dysphagia lusoria depends on the severity of the symptoms. Surgical resection and ligation of the aberrant blood vessel with or without endovascular prosthesis may be required in severe dysphagia with weight loss. Symptomatic treatment and dietary modification play an important role in management of mild to moderate dysphagia (like in our patient) [5].

Differential Diagnosis List

Final Diagnosis

Dysphagia lusoria

URL:	https://www.eurorad.org/case/11689
DOI:	10.1594/EURORAD/CASE.11689
ISSN:	1563-4086