S4269 Dysphagia Lusoria in an Adult: A Rare Vascular Cause of Esophageal Dysphagia

Introduction: Dysphagia lusoria is a rare cause of esophageal compression, most commonly due to an aberrant right subclavian artery (ARSA), a congenital vascular anomaly present in 0.5–2% of the population. While often asymptomatic, esophageal compression may present later in life due to arterial stiffening or aneurysmal dilation, often leading to misdiagnosis and extensive gastrointestinal workups. Case Description/Methods: A 52-year-old woman with a complex medical history including supraventricular tachycardia, tobacco use, depression, anxiety, and trigeminal neuropathy presented with a year-long history of persistent globus sensation and progressive neck pain. She reported worsening dysphagia and odynophagia over 2 weeks prior to admission. Extensive outpatient evaluations by ENT, neurology, and multiple gastroenterologists included multiple esophagogastroduodenoscopies, esophageal manometry, pH testing, and speech evaluations. These studies revealed mild pharyngeal dysphagia and gastritis but were otherwise inconclusive. Labs were notable for mild leukopenia (WBC 3.3 × 10³/µL). Imaging with computed tomography angiogram revealed an ARSA extrinsically compressing the esophagus. A modified barium swallow demonstrated mild esophageal indentation with contrast retention at the site of vascular impingement. Surgical correction was considered but ultimately deferred, and the patient was discharged with close outpatient GI follow-up. Discussion: An ARSA arises from abnormal regression of the embryonic fourth right aortic arch and persistence of the right dorsal aorta. While typically asymptomatic, ARSA can cause adult-onset dysphagia due to esophageal compression by the artery itself or an associated dilated Kommerell diverticulum. Endoscopic findings are often nonspecific, frequently prompting extensive gastrointestinal evaluations. Definitive diagnosis requires vascular imaging, with computed tomography or magnetic resonance angiography offering the most accurate anatomical detail. In patients with significant symptoms, surgical correction—typically involving revascularization of the ARSA and either transection at its origin or translocation to the ascending aorta—can be curative. Dysphagia lusoria should be considered in the differential for unexplained solid food dysphagia and odynophagia, especially when imaging suggests extrinsic esophageal compression. Early vascular imaging and multidisciplinary management, including surgery when indicated, offer excellent outcomes.