DISCUSSION
We report the first case of a dysphagia of rare cause, related to a vascular malformation. The aberrant right subclavian artery or arteria lusoria is a rare cause of dysphagia which should be considered in the presence of any dysphagia unexplained by the usual endoscopic and radiological examinations.3,4,5 It is the most frequent malformation of the aortic arch and is sometimes associated with other malformations such as the presence of a bicarotid trunk or a tetralogy of Fallop.3,4 Arteria lusoria can occur in young subjects but also in older patients. We reported the case of a 70-year-old female patient who presented with dysphagia lusoria. Dandelooy et al reported a similar case in a 76-year-old patient.6 However, Khnaba et al reported a younger patient aged 45 years.3 The occurrence of dysphagia during arteria lusoria in older patients is related to atherosclerotic degeneration of the artery that promotes esophageal compression.2
Arteria lusoria is asymptomatic in 90% of cases and discovered incidentally on radiological examinations performed in other contexts.2 Clinical signs are dominated by dyspnea due to tracheal compression, dysphagia due to esophageal compression as in our patient’s case. Zapata et al described dysphagia with solids during arteria lusoria as in our patient’s case.4
The upper gastrointestinal (GI) endoscopy showed in our patient a slightly bent esophagus, there were no mucosal and parietal abnormalities. The upper GI endoscopy is the key examination to perform in case of dysphagia. It allows to search for organic causes of dysphagia, to eliminate tumor causes especially in older patients like our case.5 During lusoria dysphagia, upper GI endoscopy does not bring significant element that can orient the diagnosis but can sometimes reveal indirect signs of extrinsic compression.6
Radiological examinations play an important role in the etiological approach to dysphagia after upper GI endoscopy. The barium transit of the esophagus is indicated to look for esophageal stenosis.7 This examination was not performed in our case. Esophageal manometry may be performed depending on the clinical context and if the result of the upper GI endoscopy is normal. The injected thoracic CT scan remains the key examination for the diagnosis of dysphagia lusoria. It allows to search for extrinsic compression and to characterize the defective artery. Our patient had benefited from an injected thoracic scan showing esophageal compression of vascular origin by an aberrant right subclavian artery. According to Yang et al , the sensitivity of the thoracic CT for the diagnosis of arteria lusoria is 100%.8 Arteria lusoria was confirmed by an injected chest CT scan showing compression of the esophagus by the aberrant right subclavian artery in the absence of obvious etiologies of dysphagia. Chest CT scan could also incidentally reveal the presence of an asymptomatic arteria lusoria.8
In our case, a medical treatment was instituted associating the prescription of proton pump inhibitors and a modification of the food habits, the taking of semi-liquid meals was privileged. In the case of moderate symptoms without any impact on the patient’s nutritional status, medical treatment with proton pump inhibitors combined with hygienic and dietary measures is indicated.9 The association with prokinetics has not shown any additional efficacy. Surgical treatment is discussed in the presence of severe symptoms with weight loss and undernutrition. It consists of reconstruction of the aberrant artery. The benefit-risk ratio must be evaluated before this procedure. The patient should be referred to an expert vascular surgery center.2-9