LAUSR

© BMJ Publishing Group Limited 2022. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 59yearold man with a medical history of hypertension presented to the hospital with chest discomfort with swallowing and a feeling of food ‘getting stuck’ in his chest on swallowing solids. The patient had dyspnoea on exertion but denied any orthopnoea, dizziness, lower extremity swelling or palpitations. On physical examination, his blood pressure was significantly elevated to 250/130 mm Hg, and breath sounds were slightly diminished bilaterally on auscultation without any wheezing or crackles. On presentation, his troponin I was elevated to 4.65 ng/L (0.00–0.06 ng/L), which increased to 32.6 ng/L. ECG did not show any STsegment or Twave changes. CT of the neck with contrast showed a nonspecific narrowing of the supraglottic airway without any mass or fluid collection and a retrooesophageal/retrotracheal aberrant right subclavian artery (figure 1). The patient was started on aspirin, ticagrelor, intravenous heparin and atorvastatin. Left coronary angiogram through right radial access showed a proximal occlusion of the left circumflex artery, and a drugeluting stent was placed. Arteria lusoria accounted for the clinical dysphagia that the patient reported as his oesophagogastroduodenoscopy was found to be negative. This case illustrates the significance of an anomalous retrooesophageal right subclavian artery resulting in dysphagia symptoms that may be found incidentally on the coronary angiogram. Anomalous right subclavian artery (ARSA) is also known as arteria lusoria. It is one of the most common aortic arch anomalies with a prevalence of around 0.5%–2.5% in the general population. The right subclavian artery originates as the last branch of the aortic arch, travels towards and then down the right arm after crossing the midline of the body commonly, between the oesophagus and vertebral column (80% of cases) and less commonly, between the trachea and oesophagus (15% of cases). Most patients remain symptomfree throughout their lifetime, while others can develop symptoms of dysphagia, dyspnoea, coughing, pyrosis, retrosternal pain, acute limb ischaemia and even Horner’s syndrome. The clinical manifestations of arteria lusoria result from the compression of the oesophagus by the anteriorly placed right common carotid artery and trachea with the posteriorly coursing right subclavian artery. In 0.05%–0.1% of the population, dysphagia lusoria can also result from a left subclavian artery in the presence of a rightsided aortic arch and leftsided ligamentous arteriosum, which causes more severe symptoms due to the formation of a true vascular ring that constricts the oesophagus and trachea more significantly compared with the ARSA. Our patient presented with chest pain secondary to a nonST segment elevation myocardial infarction and dysphagia, which was secondary to a retrooesophageal aberrant right subclavian artery. Patients are usually treated symptomatically with proton pump inhibitors, alcohol and smoking cessation, but surgical intervention may be required if symptoms become severe and intractable. Figure 1 CT neck with contrast illustrating arteria lusoria, an aberrant right subclavian artery (red arrow) originating from the left side of the heart and coursing behind the oesophagus. (A) Axial section; (B) coronal section.