A Rare Cause of Dysphagia by Extrinsic Compression

A 38-year-old man presented with dysphagia for solids fluctuating in severity. This symptom had persisted for several years. He reported feeling worse in the previous month, having also lost 10% of total weight. He had no relevant past medical history and physical exam was normal.

Initial workup by upper endoscopy was normal. High-resolution esophageal manometry excluded outflow obstruction of the esophagogastric junction or peristalsis disorders but identified a horizontal and pulsatile high-pressure area below the upper esophageal sphincter (Fig. 1a, b, see arrows). The initial interpretation of the manometry, as the high-pressure area maintained itself throughout the exam, gave rise to the search for an extrinsic cause. Barium swallow was then performed, revealing an extrinsic compression at the level between the upper and middle thirds of the esophagus (Fig. 2a, b, see arrows). A thoracic computed tomography angiography identified an abnormal origin to the right subclavian artery, after the left subclavian origin (Fig. 3, see arrow).

The patient refused surgical intervention and maintains mild symptoms under general measures. The abnormal right subclavian artery, also known as the arteria lusoria, is present in 0.5–2.5% of the general population and causes symptoms in about 20% [1]. Despite being congenital, it leads to dysphagia more frequently after the 5th decade of life [2]. The present case intends to raise awareness to the potential role of high-resolution manometry in the diagnosis of this rare condition.