Upper Gastrointestinal Bleeding From Aberrant Right Subclavian Artery-Esophageal Fistula

Abstract

Background:The most common aortic arch abnormality is an aberrant right subclavian artery (ARSA). ARSA-esophageal fistula is a rare sequela that can present with a life-threatening upper gastrointestinal (GI) bleed. Case Report: We report the case of an 88-year-old male who presented with signs of upper GI bleeding. Esophagogastroduodenoscopy demonstrated extrinsic compression of the upper third of the esophagus with ulceration. Imaging studies revealed ARSA posterior to the esophagus with pseudoaneurysm formation. These findings confirmed an upper GI bleed secondary to ARSA-esophageal fistula. The patient underwent prompt embolization of the ARSA pseudoaneurysm, followed a few days later by coil embolization of the ARSA pseudoaneurysm. Despite these interventions, the patient continued to have bleeding with anemia. He and his family opted to avoid any further interventions and instead pursued comfort care. The patient was discharged to hospice and died 3 months later. Conclusion: ARSA-esophageal fistula is a rare but potentially lethal cause of upper GI bleeding. Initial signs and symptoms can be subtle, but the presence of a GI bleed requires immediate stabilization. Surgical interventions have been shown to have longerlasting success, but endovascular repair may be an option for patients who are deemed unfit for surgery but still require prompt stabilization. Regardless of the intervention, mortality rates for ARSA-esophageal fistula are high.

A rare cause of esophageal stenosis: Compression due to a thoracic osteophyte

“…There have been few reports of enlarged mediastinal and hilar lymph nodes secondary to infection and abnormalities in the right subclavian artery and other blood vessels. 4,5 Moreover, vertebral osteophytes are known to cause esophageal stenoses, and there are numerous reports of aspiration and dysphagia caused by cervical osteophytes. 1,2 Conversely, there are few reports on esophageal stenoses caused by thoracic osteophytes.…”

Case report: A unique quadruple coexisting anomaly—scimitar syndrome, atrial septal defect, vascular ring, and pulmonary sequestration

“…ARSA creates an incomplete vascular ring usually by positioning posteriorly to the esophagus towards the right axilla (80% of cases), between the trachea and esophagus (15% of cases), and anteriorly to the trachea (only 5% of cases) ( 8 ). ARSA can result in esophageal compression causing dysphagia lusoria, recurrent laryngeal nerve compression causing Ortner syndrome, and tracheal compression, which results in dyspnea ( 32 ). From embryological point of view, this anomaly develops when the right fourth aortic arch abnormally curls spirally towards the cranium, to the seventh intersegmental artery.…”