Dysphagia lusoria: problem or incidentaloma?

Abstract

Purpose of review To address the incidental versus pathogenic nature of dysphagia lusoria and to provide a review of the cause, clinical presentation, diagnosis, and treatment of this condition with respect to recent literature. Recent findings Case reports comprise the majority of recent literature concerning dysphagia lusoria. Many patients with an aberrant right subclavian artery (ARSA) have additional coexisting vascular anomalies. While most individuals present around age 50, some present as children and neonates. Of note, this population may present with dysphagia as opposed to respiratory findings alone, as previously described. In the diagnostic workup, most patients receive a battery of radiologic tests, which may not be necessary. Significantly, dietary modifications and medical management alone may resolve symptoms. Nonetheless, a wide range of operative techniques are available for the treatment of dysphagia lusoria. Summary Clinicians should have a higher suspicion for dysphagia lusoria in patients with known vascular, heart, or chromosomal anomalies. Diagnosis should begin with a barium esophagram followed by a computed tomography angiogram or magnetic resonance angiogram. Avoid unnecessary studies. In many cases, an ARSA may be an incidental finding with comorbid gastroesophageal reflux disease or another medical condition responsible for the symptoms. Medical versus surgical management should be considered on a case-by-case basis.

Dysphagia lusoria in a young patient with a concomitant aortic arch anomaly, successfully treated with surgery. A case report.

“…(3) The anatomical course of this anomalous artery can vary as it passes from the chest into the right arm. (1,4) In most cases (80%), it will cross between the esophagus and the spine.…”

Anatomic Investigation of Two Cases of Aberrant Right Subclavian Artery Syndrome, Including the Effects on External Vascular Dimensions

“…However, a more recent study showed that while 71.2% of their 141 ARSA cases reported dysphagia as a symptom, only 19.2% (27/141) possessed the bicarotid morphology [8]. In addition, in many cases of a BCT co-occurring with an ARSA, barium-contrast examination indicates that the esophagus is compressed posteriorly and obliquely at the level of the aorta [3,4,6,9,15,[18][19][20], suggesting that the ARSA is the primary contributor to esophageal compression and resulting dysphagia. There are also documented cases in which a BCT is absent or extremely mild, but dysphagia still presents [19,21].…”

“…The ARSA variant morphology develops when the right fourth aortic arch fails to develop, which results in the right seventh intersegmental artery remaining attached to the dorsal aorta, which derives the ARSA formation [2,7,8]. In approximately 80% of cases, the ARSA takes a retroesophageal course, with an interesophageotracheal course occurring in 16.7% of cases and 5% of cases traveling anterior to the trachea [7,18].…”

“…Many patients with the ARSA morphology are asymptomatic and clinical intervention is not required [5]. When necessary, both medical and surgical treatments were described to treat the associated dysphagia, depending on the severity of the symptoms, variant anatomy and treatment response [18].…”

“…For patients with less severe symptoms or those not wishing to move forward with surgical interventions, conservative management can be utilized which typically involves dietary modification as well as the use of proton pump inhibitors and prokinetic agents [11]. In a case series performed on six patients with dysphagia lusoria, conservative treatment with a proton pump inhibitor and a prokinetic agent showed to be 50% effective in treating symptoms [18].…”