S4305 A Choking Warning: Dysphagia Aortica Revealing a Life-Threatening Aneurysm

Introduction: Dysphagia refers to difficulty swallowing, typically resulting from structural or functional abnormalities of the oropharynx or esophagus. Dysphagia aortica is a rare but clinically significant condition caused by external compression of the esophagus by an abnormally dilated or tortuous aorta. It is most commonly associated with thoracic aortic aneurysms, severe aortic tortuosity, or aortic dissections. In rare cases, dysphagia aortica may be the initial—and only—manifestation of a life-threatening aortic pathology. Misdiagnosis or delays in diagnosis and treatment can result in fatal outcomes. We present a case of dysphagia aortica caused by a contained rupture of a descending thoracic aortic aneurysm, which initially presented as acute dysphagia in the emergency department. Case Description/Methods: A 52-year-old man with a significant smoking history presented to the emergency department with acute dysphagia and food impaction following a meal of steak and potatoes. Initial conservative management with glucagon was unsuccessful, prompting esophagogastroduodenoscopy for food bolus removal. During esophagogastroduodenoscopy, a pulsatile, extrinsic compression of the esophagus was noted 30–35 cm from the incisors. Given these findings, the gastroenterology team recommended cross-sectional imaging. Computed tomography of the chest with contrast revealed a contained rupture of a descending thoracic aortic aneurysm. Cardiothoracic and vascular surgery teams were consulted, and the patient underwent total aortic arch replacement using the elephant trunk technique. Postoperatively, the hospital course was complicated by sepsis secondary to pneumonia, respiratory failure, and acute kidney injury. Following multidisciplinary discussions and per the family's wishes, care was transitioned to comfort measures. Discussion: Dysphagia aortica is a rare and underrecognized clinical entity, often reported only in isolated case studies. It is more frequently observed in older individuals with predisposing vascular risk factors. Because it may be the first sign of a life-threatening aortic condition, prompt recognition is critical. Early imaging is essential for diagnosis, especially in patients presenting with food impaction and risk factors for vascular disease. We advocate for initial radiographic evaluation prior to endoscopic intervention to reduce the risk of catastrophic outcomes in appropriate clinical contexts.