Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature

Abstract

An aberrant right subclavian artery (ARSA) is a common aortic arch abnormality. A case of a 57-year-old man presenting with melena and hypotension secondary to an ARSA-esophageal fistula is reported. The current report is unique because it is the first reported case of ARSA-esophageal fistula associated with prior esophagectomy and gastric pull-up. A MedLine search was performed for ARSA-esophageal fistula cases, which were then compared with the present case. Because this patient had no vascular conduits, nasogastric or endotracheal tubes, the fistula likely occurred secondary to the previous surgery. This case is unusual because the patient survived the original hemorrhage associated with the ARSA-esophageal fistula. An ARSA-esophageal fistula is a rare, but potentially fatal cause of upper gastrointestinal bleeding. A high index of suspicion is needed to make the diagnosis. This condition should be considered in patients with risk factors combined with hemodynamically significant gastrointestinal bleeding.

Figure 1)

A Initial esophagogastroduodenoscopy showing a small anastomotic ulcer. B Second esophagogastroduodenoscopy showing a small anastomotic ulcer. Note that there is no clot or active bleeding present. C Original thoracic aortic angiogram showing aneurysmal dilation at the base of an aberrant right subclavian artery (ARSA) (arrow). D Steep left posterior oblique view demonstrates recanalization of the ligated ARSA (arrow). E Steep left posterior oblique view showing ablation of the aneurysmal stump of the ARSA with the embolization coils (arrow). F Endoscopy showing embolization coils in the esophagus