Radiology Resident Case of the Week
Etiology/Pathophysiology
Dysphagia lusoria means difficulty in swallowing caused by a "Jest or Freak of Nature". Variable degrees of dysphagia have been linked to an abberrant right subclavian artery from the left aortic arch. A retroesophageal right subclavian artery is the most common aortic arch abnormality found in 0.5-1.8% of the population and is an unusal cause of dysphagia.
The embryologic abnormality of the aortic arch is the involution of the fourth vascular arch, along with the right dorsal aorta, leaving the seventh intersegmental artery attached to the descending aorta. This persistent intersegmental artery assumes a retroesophageal position as it proceeds out of the thorax to the right arm. Since compression of the esophagus by the right subclavian artery into the aortic arch may cause dysphagia, the term dysphagia lusoria has been used to describe the symptom complex. The presence of an aneurysm of the artery or KommerallŐs diverticulum at its aortic origin is more likely to produce symptoms. However, other researchers believe that the dysphagia is a result of an esophageal dysmotility and not caused by vascular compression.
Pathology:
Miscellaneous
Imaging
Imaging of dysphagia lusoria includes barium swallow study of the esophagus, CT, aortography, and magnetic resonance angiography.
Management
Management of the dysphagia is as controversial as the supposed cause of it. Those who believe dysmotility is to blame treat with cisapride.
Researchers who believe vascular compression is the cause have purposed surgical interventions. Two approaches are commonly used. In the intrathoracic approach the right subclavian artery is translocated with an interposition graft to the aorta. The extra thoracic approach uses a right supraclavicular incision to translocate the right subclavian artery to the right common carotid artery. Still other use endoscopic dilation of the esophagus as a temporizing measure.
DDX
Key references
Diagnostic Evaluation and Surgical Management of the aberrant right subclavian artery. Harms J Vogel T Ennler J Bildgebung. 61 (4):299-303.1994 Dec
Dysphagia Lusoria: Aberrant right subclavian artery with a Kommerell's diverticulum Brown DL Chapman WC American Surgeon 59(9):582-6,1993 Sep
Dysphagia Lusoria: Extrathoracic surgical management Talor M Harris KA Casson AG Canadian Journel of Surgery 39(1):48-52
ACR Code
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