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