The Unpredictable Nature of a Vascular Anomaly With Divergent Clinical Presentations

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

INTRODUCTION: Dysphagia lusoria is a rare vascular compression syndrome caused by an aberrant right subclavian artery (ARSA) compressing the esophagus. Despite its anatomical presence, clinical manifestations vary significantly among patients with ARSA. We present two cases highlighting the spectrum of presentations: one symptomatic and one asymptomatic, providing insight into the clinical heterogeneity of this condition. CASE PRESENTATION: Case 1: A 75-year-old man with Type 2 achalasia status post laparoscopic Heller myotomy and Dor fundoplication (2020), autoimmune hemolytic anemia on rituximab, autoimmune hepatitis on azathioprine, and coronary artery disease status post percutaneous intervention presented with hypoxic respiratory failure requiring supplemental oxygen. Computed tomography pulmonary angiography revealed an incidental retroesophageal right subclavian artery with patulous fluid-filled esophagus. The patient reported baseline dysphagia but no worsening symptoms during this presentation. Prior esophagogastroduodenoscopy (2022) had revealed moderately dilated esophageal lumen with retained fluid and food throughout the esophagus. His hospital course was complicated by non-occlusive myocardial infarction requiring coronary stenting, which precluded endoscopic evaluation during admission. Radiographic evidence demonstrated patulous esophagus at the aberrant subclavian artery site consistent with dysphagia lusoria. The patient was scheduled for outpatient esophagogastroduodenoscopy for further evaluation. Case 2: A 95-year-old woman with history of asthma and hypertension presented with acute dyspnea and hypoxic respiratory failure secondary to asthma exacerbation requiring high-flow oxygen therapy. CT angiography revealed an aberrant right subclavian artery alongside a moderate hiatal hernia, peribronchial thickening, and right lower lobe opacities suggestive of aspiration. Despite the anatomic vascular anomaly that typically causes esophageal compression, she demonstrated neither patulous esophagus on imaging nor reported any dysphagia symptoms when specifically questioned about swallowing difficulties. She was treated for asthma exacerbation and aspiration pneumonia. This case illustrates the incidental nature of aberrant right subclavian artery, which may remain clinically silent without causing dysphagia. DISCUSSION: These cases illustrate the clinical variability of dysphagia lusoria. While ARSA is a well-documented vascular anomaly, its clinical significance remains unpredictable. Our 75-year-old individual exhibited dysphagic symptoms with radiographic evidence of esophageal compression, whereas the 95-year-old individual remained asymptomatic despite the presence of ARSA. The latter case raises the possibility of subclinical esophageal compression due to vascular anomaly contributing to her aspiration pneumonia, highlighting the potential for occult consequences of this anomaly. These cases emphasize the need for heightened clinical suspicion when evaluating unexplained dysphagia, particularly in patients with vascular anomalies. Given that ARSA is often identified incidentally on imaging, clinicians may underappreciate its role in esophageal dysfunction, leading to delayed or missed diagnoses. CONCLUSIONS: In conclusion, dysphagia lusoria presents along a continuum from asymptomatic to clinically significant, in which anatomical variation alone is insufficient to predict clinical impact. Symptom expression in dysphagia lusoria likely depends on multiple factors beyond anatomical compression, including esophageal motility and luminal compliance. The presence of ARSA alone does not dictate clinical significance, as some patients remain asymptomatic while others develop progressive dysphagia or complications such as aspiration. A thorough clinical assessment, including imaging and functional studies when appropriate, is essential to distinguish incidental findings from clinically relevant disease and to guide management decisions effectively.

Volume

168

Issue

4S

First Page

4654A

Last Page

4655A

Comments

American College of Chest Physicians CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

DOI

10.1016/j.chest.2025.07.2609

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