A Pseudoaneurysm of Aberrant Right Subclavian Artery Caused by Esophageal Stent Placement Because of Esophageal Stricture After Endoscopic Submucosal Dissection

Abstract

A 67-year-old man who received endoscopic submucosal dissection for an early squamous esophageal cancer was hospitalized for dysphagia. The mucosal defect was over three quarters of the circumference, and the distal edge of the resection scar formed the stenosis after 8 months. After experiencing conservative treatment, probe expansion, and esophageal stent placement, the symptom of deglutition disorder in the patient was improved, but persistent hemorrhage and progressive anemia occurred in the short term. An enhanced neck and chest computed tomography (CT) showed a contrast agent leaked from the aberrant right subclavian artery to the esophagus. A pseudoaneurysm of the aberrant right subclavian artery and subclavian artery-esophageal fistula were diagnosed by CT angiography. Although false aneurysms developing after iatrogenic injury and trauma have been reported, those caused by esophageal stent placement because of esophageal stricture after endoscopic submucosal dissection have not. When persistent hemorrhage and progressive anemia develop after esophageal stent placement, an enhanced CT should be performed to exclude the false aneurysm.

Upper Gastrointestinal Bleeding From Aberrant Right Subclavian Artery-Esophageal Fistula

“…14,15,17,19,21,22,24,27,29,31,[38][39][40][41] Fistula development from prior placement of esophageal stent was noted in 5 cases. 34,36,42,43 Other reported causes for fistula formation included placement of a salivary bypass tube and a possible consequence of gastric pull-up surgery. 1,26 Fistula formation attributable to ARSA aneurysm with resultant GI bleeding is rare.…”

“…Only 10 other cases attributed to this etiology have been reported. 11,12,16,18,19,23,25,33,35,42 Only 1 patient with upper GI bleed secondary to ARSA aneurysm survived all bleeding episodes, and the patient required balloon tamponade with surgery to replace the aorta. 33 Our patient survived the initial bleeding event, but died 3 months later, as he declined definitive surgical intervention to stop the recurrent bleeding.…”

“…33 A more recent approach (2000) is placement of an endovascular stent, but success with this approach is questionable because of the rates of infection that may result in the need for further surgery. 44 Reported cases in adults involved treatment with surgery alone in 5 cases, 11,16,26,30,38 endovascular repair alone in 2 cases, 41,42 and a combination of endovascular and surgical intervention in 6 cases. 28,29,31,35,36,43 Balloon tamponade was performed in 16 cases, 1,14,15,21,22,24,25,27-29,31-33,35-37 with 3 of those 16 performed solely with endovascular repair.…”

Esophageal regenerative therapy using cell sheet technology

“…Mechanical strategies for EBD [ 4 ], self-expandable metallic stent (SEMS) implantation [ 41 ], and biodegradable stent implantation [ 61 ] have a potential risk of perforation. A pseudoaneurysm of aberrant right subclavian artery caused by esophageal stent placement because of esophageal stricture after ESD was also reported [ 62 ]. Oliveira et al.…”