Anomalous Right Subclavian Artery-Esophageal Fistulae

Abstract

An aberrant right subclavian artery (ARSA) is the most common aortic arch anomaly, but only 19 previous cases of ARSA-esophageal fistula have been reported. Six patients have survived their bleeding episode. We describe the case of a 44-year-old woman who developed massive hemoptysis. Laryngoscopy, bronchoscopy, head and neck angiogram, and median sternotomy did not reveal what was presumed initially to be a tracheoinnominate fistula. Contrasted CT showed an anomalous subclavian artery posterior to the esophagus. Given the technical challenge of approaches for this pathology, the patient was unfit for open surgical repair. Therefore, endovascular covered stent grafts were deployed spanning the segment of the subclavian artery in continuity with the esophagus, via a right brachial artery approach. Unfortunately, the patient died after successful placement of the grafts.

Aberrant Left Subclavian Artery-Esophageal Fistula in a Patient with a Prolonged Use of Nasogastric Tube: A Case Report and Literature Review

“…Previously, aortic arch anomalies have been reported as a miscellaneous etiology of aortoesophageal fistulae [ 1 ]. A review of previously reported cases of aberrant subclavian artery-esophageal fistulae revealed the prolonged use of devices such as NG and endotracheal (ET) tubes as a major contributing factor [ 2 , 5 , 10 , 11 , 12 , 13 , 14 , 15 ]. NG and ET tubes are believed to create pressure necrosis and erosion on the area of the esophageal wall that is in contact with the tubes [ 2 , 11 ].…”

“…Although some cases were associated with esophageal cancer or recent procedures such as surgery and stent insertion, fistulae could be attributable to a prolonged use of NG and/or ET tubes in more cases. Therefore, some authors recommend screening intensive care patients and avoiding the long-term use of NG or ET tubes in patients with an aberrant subclavian artery [ 12 , 13 ]. Since conventional surgical repair takes considerable time, endovascular treatment such as temporary balloon occlusion or stent insertion is commonly performed for rapid bleeding control [ 29 , 30 , 31 , 32 ].…”

An Elegant Solution to a Ruptured Right Aberrant Subclavian Artery after Oesophageal Stent Removal

“…Arterioenteric fistula is a rare complication of ARSA, most commonly associated with prolonged nasogastric (NGT) or endotracheal intubation (ETT), or presence of an oesophageal stent [2]. Diagnosis is difficult as patients present with rapid unexplained exsanguination with overwhelming haematemesis.…”

“…When these techniques are not possible, the final option is for thoracotomy or sternotomy to establish proximal arterial control via cross clamping of the aorta [6]. We describe the first case in the literature of an ARSA-esophageal fistula managed endovascularly without thoracotomy or sternotomy [2].…”

“…An aberrant right subclavian artery (ARSA) is a common aortic arch anomaly, with an incidence of 0.5-1% [1,2]. Embryologically, it is caused by regression of the fourth aortic arch between the carotid and subclavian arteries [1][2][3] to originate distal to the left subclavian artery origin, coursing behind the oesophagus [2,4]. Arterioenteric fistula is a rare complication with mortality upwards of 70% [2].…”