A 66 y.o. woman with seronegative rheumatoid arthritis presents with chest pain.

What do you notice on her CTA?

Hint: it is a vessel that normally belongs on the right

where is the esophagus

Our patient had dysphagia lusoria.  This is an unusual condition in which chest pain or painful swallowing  is caused by an aberrant R subclavian artery  which  compresses the esophagus.

 An aberrant subclavian artery occurs in 1.8% of people however only about 1/3 experience symptoms.  The symptoms reported include pain from esophageal dysfunction and shortness of breath from external compression of the trachea or pulmonary artery.  It can present late in life  because of progressive atherosclerosis of subclavian artery or aneursymal dilation.

obstruction can be seen on UGI caused by an aberrant subclavian

While dysphagia lusoria ia an uncommon condition which can be symptomatically improved by surgery. This is not to be confused with  globus pharyngeus which is a painless sensation of a lump in the throat, or a tightening which is not amenable to surgical treatment.  This  makes up 4% of ENT referral and is reported to have been experienced by up to 45% of the population.  The causes of this condition are not known and theories include: reflux, goiters, anxiety and rarely, hypopharyngeal cancer.

The causes of dysphagia can be divided into oropharyngeal and esophageal sources. A useful chart is shown below.

Our patient had complained of difficulty swallowing for four months prior to her presentation with chest pain.  Myocardial enzymes and EKGs were normal and after the CTA confirming an aberant subclavian she was referred to vascular surgery for a repair.

Dandelooy J, Coveliers J, Schil P, et al. Dysphagia lusoria. CMAJ 2009 Oct 13;181(8):498.

Ahmed Z, Udongwo N, Albustani S, et al. Dysphagia Lusoria: a little known cause of chest  pain.  Cureus 13(12):e20085.doi:10.7759/cureus.20085

Jones D, Globus pharyngeus: an update for general practive, Br J Gen {ract 2015 Oct;65(639:554-555.