A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/245728
22 A Case Report Bariatric Times • January 2014 B FIGURE 2. Upper GI series, demonstrating abnormal tortuosity and tapering of the mid to upper thoracic esophagus in the region of the aortic arch; AP view (A) and lateral view (B) A B FIGURE 3. Chest computed tomography (CT) scan with intravenous and oral contrast, sagittal view. Aberrant right subclavian artery (ARSA) compressing the esophagus. aberrant right subclavian artery. Patients who are asymptomatic and in whom this is an incidental finding may defer surgical correction.12 Patients with quality-of-life limiting symptoms, however, generally require surgical correction. Various surgical approaches have been described, with proximal occlusion of the lusorian artery by a cervical, supraclavicular, median sternotomy, or left- or right-sided thoracotomy approach in conjunction with transposition of the right subclavian artery.5 Some advocate for an extrathoracic approach in adult patients, as adequate visualization and mobilization can occur via a supraclavicular approach while minimizing the possible complications of a thoracotomy or sternotomy.14 In the pediatric population, a right thoracotomy approach allows for optimal mobilization of the distal aberrant right subclavian artery and enables end-to-end anastomosis to the ipsilateral common carotid artery without the necessity of graft interposition.10 Recent hybrid operations, involving combined endovascular and operative treatments, have been reported for the management of aortic vascular disorders.5 The use of an Amplatzer plug in combination with a carotid subclavian bypass15 as well as a Zenith iliac plug for proximal occlusion of the Kommerell's diverticulum16 are two such hybrid techniques that have been reported. It is clear that re-establishment of retrograde flow in the right subclavian artery is necessary to prevent limb weakness and ischemia and resultant subclavian steal syndrome. CONCLUSION A B FIGURE 4. Chest computed tomography (CT) scan with intravenous and oral contrast, axial view. Aberrant right subclavian artery (ARSA) compressing the esophagus. FIGURE 5. Chest computed tomography (CT) scan with intravenous and oral contrast, coronal view. Aberrant right subclavian artery compressing the esophagus. This patient's presentation is unique in both her age and timing following bariatric surgery and subsequent weight loss. The workup for the patient's dysphagia and vomiting included esophagogram, upper endoscopy, and chest CT scan, which clearly demonstrated the aberrant right subclavian artery (ARSA). We suspect that her symptoms may be related to her precipitous weight loss, which allowed for subsequent compression by the artery on the posterior esophagus. This hypothesis is supported by the patient's symptoms that developed and progressed after substantial weight loss. The patient had no previous upper GI swallow study for comparison.