Aberrant right subclavian artery

Aberrant right subclavian arteries (ARSA), also known as arteria lusoria, are one of the commonest of the aortic arch anomalies. 

Epidemiology

The estimated incidence is 0.5-2%.

Clinical presentation

They are often asymptomatic, but around 10% of people may complain of tracheo-esophageal symptoms, almost always as dysphagia, termed dysphagia lusoria ³.

Pathology

Course

Instead of being the first branch (with the right common carotid as the brachiocephalic artery), it arises on its own as the fourth branch, distal to the left subclavian artery. It then hooks back to reach the right side with its relationship to the esophagus variable:

• 80% posterior to the esophagus
• 15% between esophagus and trachea
• 5% anterior to the trachea

Associations

• as can be expected from the embryological development of the artery, the right recurrent laryngeal nerve is usually non-recurrent (that is, enters the larynx directly)
• aneurysmal dilatation (aberrant subclavian arterial aneurysms) of the proximal portion of an aberrant right subclavian artery can occur, a pouch-like aneurysmal dilatation is called a diverticulum of Kommerell
• if there is a retro-esophageal course
  • it can get compressed between the esophagus and the vertebra
  • the incidence of stenosis/occlusion in this segment is higher
• it can be associated with trisomy 21 ⁵, trisomy 18 and other chromosomal defects.

Radiographic features

Fluoroscopy

An upper GI contrast study will demonstrate displacement of the contrast-filled esophagus. This displacement by the aberrant vessels produces the so-called bayonet deformity of aberrant right subclavian artery.

CT/MRI

CT and MRI both demonstrate the aberrant branch arising from the distal left aortic arch and coursing rightwards, and can define the relationship between the aberrant artery and the trachea and esophagus.

Complications

The presence of aberrant right subclavian artery poses a substantial risk of life-threatening hemorrhage in patients undergoing surgery like esophagectomy. Moreover, the recurrent laryngeal nerve does not follow the orthodox course which is of importance in thyroid and parathyroid surgeries ⁶.