S4275 Dysphagia Lusoria Due to Aberrant Right Subclavian Artery and Kommerell Diverticulum With Thoracic Arch Aneurysm: A Multimodal Diagnostic and Surgical Success

Introduction: Dysphagia lusoria is an uncommon cause of esophageal compression, most often due to an aberrant right subclavian artery (ARSA), which is sometimes associated with a Kommerell diverticulum and a thoracic aortic aneurysm. This case illustrates the diagnostic complexity and multidisciplinary management of a patient with progressive dysphagia ultimately resolved by advanced vascular intervention. Case Description/Methods: A 62-year-old woman with a history of rheumatoid arthritis, hypothyroidism, and prior thyroidectomy presented with several years of progressive dysphagia. She denied weight loss, regurgitation, or significant aspiration. A double-contrast esophagram demonstrated a 2.5 cm well-circumscribed mucosal abnormality with focal narrowing in the proximal esophagus, just above the aortic knob. An upper endoscopy showed the presence of a pulsatile soft tissue indentation of the proximal esophagus. This tissue indentation was around 20 cm from the incisors and showed no signs of stricture or submucosal mass. An endoscopic ultrasound verified a moderate traversable extrinsic compression of the top third of the esophagus by a vascular structure. This was likely an aberrant right subclavian artery. There was also no evidence of mediastinal or subepithelial mass. A computed tomography angiogram of the chest was also performed. It demonstrated an aberrant right subclavian artery arising distal to the left subclavian artery, associated with a Kommerell diverticulum and a thoracic arch aneurysm. Given continued symptoms and vascular findings, the patient underwent endovascular thoracoabdominal aneurysm repair. This included coverage of the left subclavian artery and ARSA, as well as right open subclavian-to-carotid artery transposition and left subclavian artery stenting. Postoperatively, the patient developed transient mild pharyngeal dysphagia and Horner's syndrome, which were managed conservatively. Discussion: This case highlights the diagnostic complexity and rarity of dysphagia lusoria due to ARSA with associated Kommerell diverticulum and thoracic arch aneurysm. While ARSA is the most common aortic arch anomaly, most individuals remain asymptomatic, and the development of significant compressive symptoms in adulthood—especially in the presence of aneurysmal degeneration—is rare. The patient's successful management with a hybrid endovascular and open surgical approach underscores the importance of multidisciplinary care in rare vascular causes of dysphagia.