Dysphagia Lusoria: Five Years Following Gastric Bypass Surgery

by Wasef Abu-Jaish MD, FACS; Molly Wasserman, MD; Mohammad Jafferji, MS-III; and Vishal Shah, MS-III

Drs. Wasef Abu-Jaish and Molly Wasserman are from the University of Vermont College of Medicine, Fletcher Allen Health Care, Minimally Invasive and Bariatric Surgery, Burlington, Vermont. Mohammad Jafferji and Vishal Shah are third-year medical students at University of Vermont College of Medicine.

Funding: No funding was provided.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.ABSTRACT
Aberrant right subclavian artery is a congenital malformation of the aortic arch which is most often asymptomatic but a small percentage of patients can develop symptoms during their adult life. The authors report a rare case of an adult patient with symptomatic aberrant right subclavian artery five years following Roux-en-Y gastric bypass for morbid obesity.

INTRODUCTION
Roux-en-Y gastric bypass (RYGBP) is the most commonly performed operation for the treatment of morbid obesity in the United States.[1] Nausea and vomiting are reported to be the most common complaints after bariatric surgery and are typically associated with nonadherence to the dietary recommendations. One of the most common complications causing nausea and vomiting in gastric bypass patients is anastomotic ulcers, with and without stomal stenosis.[2] Vomiting after a RYGBP is not an uncommon symptom and it has been reported that 1 to 5 percent of the patients may experience uncontrolled vomiting after the operation.[3] Endoscopy and upper GI radiological contrast studies are sufficient to confirm the diagnosis of the stenosis.

Here, we present a case of a patient who experienced nausea, vomiting, hypersalivation, and dysphagia five years following RYGB. An upper GI study confirmed that the patient’s symptoms were caused by aberrant right subclavian artery, or arteria lusoria.

To our knowledge, this is the second case reported in the literature.[4]

CASE REORT
A 59-year-old Caucasian woman with a history of an open RYGB operation (2006) presented to a local emergency department with the chief complaint of a one-month history of progressively worsening epigastric pain, chest pain, and dysphagia with associated foaming at the mouth. Her symptoms initially occurred 30 minutes postprandially and were associated with lying supine; as the month progressed, pain also began occurring with sitting and standing. Two days prior to presenting at our hospital, she had presented to an outside hospital with similar complaints. Extensive cardiac workup was negative for an acute coronary syndrome and she was discharged home with instructions to follow up at the bariatric clinic. Her symptoms worsened, and she presented to our hospital with increased chest pain, dysphagia, and hypersalivation. She reportedly had been tolerating soft foods and liquids, but had difficulty eating solids. Her pain was associated with nausea and non-bilious emesis with her remaining review of systems being negative. The patient’s past medical history prior to the gastric bypass surgery comprised type 2 diabetes, hypercholesterolemia, hypertension, gastroesophageal reflux disease (GERD), and stress urinary incontinence. Her past surgical history was significant for a total abdominal hysterectomy with bilateral salpingo-oopherectomy, open appendectomy, open cholecystectomy, left rotator cuff repair, and bilateral carpal tunnel release.

Upon arrival, the patient was hemodynamically stable. Except for mild epigastric tenderness to deep palpation, her exam was unremarkable. Laboratory findings were significant for hypokalemia and hypomagnesaemia, but hemogram, liver function tests, lipase, and cardiac enzymes were normal. An acute abdominal series showed no intra-abdominal free air or clear evidence of obstruction. Upper endoscopy showed no obvious cause of the patient’s dysphagia. The gastric pouch was normal in size without evidence of bile reflux or gastro-gastric fistula. The gastro-jejunal anastomosis was patent without evidence of stricture or marginal ulceration (Figure 1). The patient subsequently underwent an upper GI series with a small bowel follow-through (Figure 2) demonstrating abnormal tortuosity and tapering of the mid- to upper-thoracic esophagus in the region of the aortic arch. A computed tomography (CT) scan of the chest with contrast demonstrated an aberrant right subclavian artery that was compressing the esophagus (Figure 3, Figure 4, Figure 5).

Regardless of cardiothoracic surgery’s recommendations, the patient declined any surgical intervention and sought another opinion in her home town. The patient was discharged with instructions to follow up with a cardiothoracic surgeon and our bariatric clinic as an out-patient.

DISCUSSION
Aberrant right subclavian artery, or arteria lusoria, is a congenital malformation of the aortic arch in which four vessels arise sequentially from the arch in the following manner: right common carotid artery, left common carotid artery, left subclavian artery, aberrant right subclavian artery. It is most often asymptomatic, but a small percentage of patients can develop symptoms, including dysphagia, tracheal compression, upper extremity ischemic complications, or aneurysmal dilatation, requiring surgical intervention. Initially described by Bayford.[5,6] in 1794, this aberration is the most common congenital intrathoracic aortic arch abnormality7 with a prevalence of 0.5 to 2.5 percent.[8,9] In normal embryologic development, the right subclavian artery is formed by fusion of the persistent right dorsal aorta proximally with the right seventh intersegmental artery distally.[6] Aberrancy of the right subclavian artery occurs when there is involution of the right fourth vascular arch and proximal right dorsal aorta, and persistence of the seventh intersegmental artery which originates from the proximal descending thoracic aorta. The usual path for this aberrant vessel is to course superiorly and to the right through the posterior mediastinum.[7] The aberrant vessel crosses behind the esophagus 80 to 84 percent of the time, with the remainder of cases crossing either between the esophagus and the trachea (12.7–15%) or in front of the trachea (4.2–5%)7. Up to 60 percent of patients with this anomaly have an aberrant artery in which the lumen at the origin is wider than that of the rest of the thoracic subclavian artery, resulting in an infundibulum, also known as a “Kommerell’s diverticulum”.[7]

When children with this aberrancy are symptomatic, they present with respiratory difficulties including stridor, cough, and respiratory infections.10 Asymptomatic aberrant right subclavian arteries in adulthood are generally found incidentally. Five percent of adults with this anomaly are symptomatic, such as the patient presented in this case report. Dyspnea, chronic coughing, and dysphagia, termed dysphagia lusoria, are the usual presenting symptoms in adulthood. These symptoms are likely due to the development of atherosclerosis or fibromuscular dysplasia with dilation of a Kommerell’s diverticulum compressing on the trachea or esophagus11 leading to increased rigidity of the esophagus or fibrous transformation of the paratracheal and esophageal tissues.[6,10]

Imaging techniques that are most helpful in the diagnosis of an aberrant right subclavian artery include a barium-contrast esophagogram, demonstrating the characteristic diagonal compression defect at the level of the third and fourth vertebral levels, CT scanning, and angiography10. Identification of this anomaly pre-operatively is critically important,[7] especially as this aberrant vascular pattern may pose a challenge for endovascular clinicians. Recent investigation into the use of multidetector computed tomography (MDCT) has shown it to be a useful diagnostic tool in evaluating vascular abnormalities as a cause for dysphagia.[13]

Due to the rarity of this condition, there is no standard-of-care for the treatment of an aberrant right subclavian artery. Patients who are asymptomatic and in whom this is an incidental finding may defer surgical correction.[12] Patients with quality-of-life limiting symptoms, however, generally require surgical correction. Various surgical approaches have been described, with proximal occlusion of the lusorian artery by a cervical, supraclavicular, median sternotomy, or left- or right-sided thoracotomy approach in conjunction with transposition of the right subclavian artery.[5] Some advocate for an extrathoracic approach in adult patients, as adequate visualization and mobilization can occur via a supraclavicular approach while minimizing the possible complications of a thoracotomy or sternotomy.[14] In the pediatric population, a right thoracotomy approach allows for optimal mobilization of the distal aberrant right subclavian artery and enables end-to-end anastomosis to the ipsilateral common carotid artery without the necessity of graft interposition.10 Recent hybrid operations, involving combined endovascular and operative treatments, have been reported for the management of aortic vascular disorders.[5] The use of an Amplatzer plug in combination with a carotid subclavian bypass15 as well as a Zenith iliac plug for proximal occlusion of the Kommerell’s diverticulum[16] are two such hybrid techniques that have been reported. It is clear that re-establishment of retrograde flow in the right subclavian artery is necessary to prevent limb weakness and ischemia and resultant subclavian steal syndrome.

CONCLUSION
This patient’s presentation is unique in both her age and timing following bariatric surgery and subsequent weight loss. The work-up for the patient’s dysphagia and vomiting included esophagogram, upper endoscopy, and chest CT scan, which clearly demonstrated the aberrant right subclavian artery (ARSA). We suspect that her symptoms may be related to her precipitous weight loss, which allowed for subsequent compression by the artery on the posterior esophagus. This hypothesis is supported by the patient’s symptoms that developed and progressed after substantial weight loss. The patient had no previous upper GI swallow study for comparison.

References
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Tags: Dysphagia lusoria, gastric bypass surgery

Category: Case Report, Past Articles