Aberrant Right Subclavian Artery - Esophageal Fistula.

SESSION TYPE: Miscellaneous Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: An aberrant right subclavian artery (ARSA) is the most common anatomical abnormality of the aortic arch, found in 0.5-1.8% of autopsies. Fistula formation between a non-aneurysmal retro-esophageal ARSA and the esophagus is exceptionally rare. (1)CASE PRESENTATION: A 44 year-old woman with history of hypertension, GERD, presented to the Emergency Department with rapidly progressive dyspnea and coffee-ground emesis. Initial findings included hypothermia (36.3 C), hypotension (97/43), tachypnea (respiratory rate 28) and hypoxemia (oxygen saturation 90% on room air). Chest radiograph showed a right lower lobe infiltrate with pleural effusion. Within hours the patient required intubation and mechanical ventilation with a high level of positive end-expiratory pressure (25 cmH2O). During her ICU stay the patient failed many weaning attempts and underwent tracheostomy. Two weeks after tracheostomy placement, the patient acutely developed copious bleeding from the mouth, nose, and tracheostomy tube. Coagulation parameters and platelet count were within normal limits (INR: 1.2, aPTT: 32 Second). The oral cavity was packed with Kerlix with transient control of bleeding. Bleeding continued and the patient was brought emergently to the operating room. A median sternotomy was performed and dissection was extended along the ascending aorta to the 1st branch that was noted to be a bicarotid trunk. The patient underwent emergent computed tomography scan with contrast that confirmed the diagnosis of Abarrent right subclavian artery- Esophageal Fistula and returned to the operating room where she had a cardiac arrest and failed resuscitative measures.DISCUSSION: Only 10% of adult patients with ARSA have symptoms. Patients usually complain of compressive symptoms, particularly dysphagia (2). The main diagnostic criterion in intensive care patients is occurrence of abrupt, massive arterial bleeding several days after placement of an endotracheal or nasogastric tube. The mechanism underlying the development of a fistula involves the induction of limited necrosis of the digestive and arterial walls by pulsatile compression of the esophageal wall between the retro-esophageal subclavian artery and rigid intubation catheter. This leads to thrombosis of the vasa vasorum as well as to ischemia of the digestive wall and with time, this leads to a fistula formation (1). The prognosis of Arterioesophegeal fistula is highly unfavorable with high mortality. (2)CONCLUSIONS: Aberrant right Subclavian Artery- Esophageal fistula should be considered in any patient who has a hematemesis of bright red blood several days after placement of an endotracheal or nasogastric tube.1) Patrick Feugier, MD,et al. Arterioesophageal Fistula: A Rare Complication of Retroesophageal Subclavian Arteries. Ann Vasc Surg. 2003 May;17(3):302-5.2) Delap TG,MD. El al. Aneurysm of an aberrant right subclavian artery presenting as dysphagia lusoria. Ann Otol Rhinol Laryngol 109:231-234, 2000.DISCLOSURE: The following authors have nothing to disclose: Ahmed Al-Badri, Wael NasserNo Product/Research Disclosure InformationMedStar Health Research Institute, Washington, DC.