case_images: PMC10656587_01
case_images: PMC10656587_02
case_images: barium oesophagogram, note the severe oesophageal stenosis at the level of the aortic arch, thoracic vertebra 4/5, caused by an extrinsic mass
case_images: PAMJ-45-183-g001.jpg
case_images: PMC10656587_02_PAMJ-45-183-g001.jpg
case_images: F1
case_images: Diagnostic approach: the contrast oesophagogram showed extrinsic compression of the upper thoracic oesophagus about the level of the arch of the aorta, Figure 1.
case_images: A) four arch vessels are noted; the 4th is seen in the posterior mediastinum just in front of the 4th thoracic vertebrum; B) at the level of the aortic arch, the 4th vessel is seen arising from the arch and coursing behind the oesophagus and anterior to the spine
case_images: PAMJ-45-183-g002.jpg
case_images: PMC10656587_02_PAMJ-45-183-g002.jpg
case_images: F2
case_images: However, the finding of a contrast-enhancing lesion of unclear nature anterior to the 4th thoracic vertebrum prompted a review of the scan with the radiologists during which the earlier described contrast-enhancing lesion was discovered to be an ARSA, Figure 2 (A,B).
case_images: A) intra-operative (left posterolateral thoracotomy), the forceps points to the left subclavian artery; the arrow points to the aberrant right subclavian artery; B) intra-operative, right supraclavicular incision (white arrow = mobilized aberrant right subclavian artery), (black arrow = right common carotid artery); C) intra-operative: aberrant right subclavian artery being anastomosed to the right common carotid artery
case_images: PAMJ-45-183-g003.jpg
case_images: PMC10656587_02_PAMJ-45-183-g003.jpg
case_images: F3
case_images: The mediastinal pleura overlying the proximal portion of the descending aorta and the arch of the aorta was incised open thereby exposing the left common carotid artery (LCCA), the left subclavian artery (LSCA) and the aberrant right subclavian artery (ARSA), (Figure 3A). It was mobilised to well behind the oesophagus and encircled, (Figure 3B). ARSA was mobilised from within the chink between the right CCA and IJV. After heparinization with 5000iu of unfractionated intravenous heparin, an end-to-side right subclavian artery to CCA anastomosis was effected using running 5/0 polypropylene suture leading to a restoration of oxygen pulse oximetry and blood pressure reading to the right upper limb, (Figure 3C).
case_images: barium oesophagogram 2 weeks post operation; oesophageal stenosis resolved
case_images: PAMJ-45-183-g004.jpg
case_images: PMC10656587_02_PAMJ-45-183-g004.jpg
case_images: F4
case_images: Follow up and outcome of intervention: a repeat barium oesophagogram 2-weeks post-surgery showed normal oesophagus, Figure 4.