Transcript Mr. Li Kam (1137844) is a 79 year

79 yo male
Pt. is a 79 year-old man with a history of Stage IV esophageal cancer
with involvement of the lung and possibly liver who began suffering from
dysphagia. The decision was made to place an esophageal stent to relieve
the malignant stricture, but the first attempt was stopped due to bleeding
during the procedure. The second attempt several days later was
successful. He presented about 6 weeks to the Cancer Clinic coughing up
blood clots, passing dark blood out his PEG tube, and passing melenic
stools. Ever since the stent placement he complained of pain in his upper
back. Physical exam demonstrated orthostatic hypotension. Labs showed
a drop in Hematocrit from 34.6 to 29.5. While in the physician’s office, he
developed frank hematemesis. Two large bore IVs were placed, and IV
fluids along with famotidine were given as the patient was taken to the ER
by ambulance.
Severe stricture is present
in the distal cervical esophagus,
with proximal esophageal
dilatation and standing air-fluid
level. A trace quantity of
contrast material passes beyond
this focal stenosis.
On second attempt, a guidwire was
passed beyond the esophageal
stricture, the stricture was balloon
dilated, and a self expanding metallic
stent was placed.
CT scan shows aberrant artery branching from a left aortic arch coursing behind
stented esophagus
DX: Left Aortic Arch With Aberrant Right
Subclavian Artery
•
•
During development, the aorta begins as a
double arch and a break occurs distal to the
right subclavian. The rest of the second arch
degrades while the proximal part becomes the
brachiocephalic artery.
If the break occurs between the common carotic
and right subclavians, the right subclavian will
arise as the final branch of the arch in a more
inferior location. The right subclavian courses
obliquely and upward behind the esophagus.
•The proximal part is really a residual part of the right arch and is
more dilated (Kommerell’s diverticulum) and prone to aneurysm.
•This variant is present in 0.5% of the population. Does not cause
vascular ring and is usually asymptomatic.
•The main complications of esophageal stents are tumor ingrowth
and stent migration. Hemorrhage is a relatively rare, but usually
fatal, complication.
Hospital Course
Pt was seen by GI in the ED. EGD was performed and arterial
bleeding was found through the distal end of the stent. The presumed cause
of the bleeding was erosion of the stent into the aberrant right subclavian
artery. The patient received a blood transfusion. Due to an inability to stop
the bleeding, he was admitted to the Palliative Care Service and his code
status was changed to DNR. He passed away about a week later.
References
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th
ed. Churchill, Livingston Inc., 2001. pp. 2215-2218.
Kaufman, JA and Lee, MJ. Vascular and Interventional Radiology: The
Requisites. Mosby, 2004. pp. 543-552.
Medical Student: Nicholas Nacey SMD ‘07