Abstract
Aberrant Right Subclavian Artery-Esophageal Fistula Presenting as Gastrointestinal Bleeding: A Case Report
Elisa Francesca G. Mendoza, MD; Jonard T. Co, MD; Ronell Q. Lee, MD; Justin Ryan L. Tan, MD
Chinese General Hospital and Medical Center
Significance: Aberrant right subclavian artery (ARSA) is a rare congenital anomaly of the aortic arch, found in 0.2–2.5% of the population. While often asymptomatic, ARSA can cause compressive symptoms such as dysphagia or dyspnea, and rarely, upper gastrointestinal bleeding due to esophageal erosions. Prolonged nasogastric tube (NGT) placement can lead to pressure necrosis and an ARSA-esophageal fistula, a life-threatening complication that may present with gastrointestinal bleeding.
Clinical Presentation: A 94-year-old female with atrial fibrillation on Apixaban, tracheostomy, and NGT presented with bloody tracheal secretions, melena, and bloody NGT output.
Management: Imaging revealed an ARSA adjacent to the trachea and esophagus. Esophagogastroduodenoscopy (EGD) showed a linear ulcer with indurated borders and a non-bleeding, pulsating vessel 18 cm from the incisors. Initial treatment with hemospray was attempted but led to subsequent hematemesis and tracheostomy bleeding, requiring vasopressors for hemodynamic stability. Repeat EGD and CT angiography confirmed contrast extravasation into the esophagus from an ARSA. Definitive management involved inserting a covered vascular stent, which effectively controlled bleeding. Follow-up EGD two weeks later showed ulcer healing and a visible, non-bleeding vessel.
Recommendation: Endoscopic placement of a Sengstaken-Blakemore tube can provide temporary hemostasis in ARSA-esophageal fistula cases. Definitive management includes open repair, thoracic endovascular aortic repair (TEVAR), or hybrid procedures. Endovascular stenting, as demonstrated, offers a minimally invasive and effective solution. This case highlights the utility of a covered vascular stent in managing ARSA-esophageal fistula and emphasizes the importance of early intervention to prevent fatal complications.
Important Dates to Remember
| JRRE Activities 2023-2024 |
Proposed Dates |
|---|---|
| Resumption of face-to-face Evidence-Based Medicine Workshop Venue to be announced once finalized. |
July 21, 2023 (Friday), 1-5pm |
| Monthly Critical Appraisal of Topics Conferences to be gaciliated by Research Coordinators per Institution | Monthly Critical Appraisal of Topics Conferences per Institution |
| CAT Plenary/Liver Con Dates: September 23, 2023 December 16, 2023 March 2024 (During the JAC) Resumption of face-to-face Quarterly Critical Appraisal of Topics facilitated by the JRRE |
2 Clinical scenarios and articles are to be sent to institutions each on August 2023, November 2023, and February 2024; |
| Hybrid Research Workshop 4 week asynchronous via Moodle, followed by a 1 day on-site Onsite Workshop Research Protocol Presentation for Level I GI Fellows-In-Training - Research Protocol Presentation: August 12, 2023 - Research Forums of the Tripartite Societies |
Week 1: July 15-21, 2023 Week 2: July 22-28, 2023 Week 3: July 29-August 4, 2023 Week 4: August 5-11, 2023 |
| Research Manuscript Workshop for level II GI Fellows-In-Training | January 6, 2024 |