**6. Diagnosis**

Although dysphagia may be the most frequent symptom demonstrated by adults, children demonstrate a different respiratory symptomatology attributed to lack of the tracheal rigidity associated with dysphagia and false routes [21]. In addition, the arteria lusoria can also be

80 Epidemiology of Communicable and Non-Communicable Diseases - Attributes of Lifestyle and Nature on Humankind

A meta-analysis by Polguj et al. found the most commonly reported symptoms related to compression of adjacent structures by an aberrant right subclavian artery to be dysphagia (71.2%), dyspnea (18.7%), retrosternal pain (17.0%), cough (7.6%), and weight loss greater than 10 kg over a six-month period (5.9%) [15]. Among the less common symptoms, stomachache, back pain, and numbness of the right upper limb were reported. The mean age of the onset of symptoms was 49.9 ± 19.4 years for the whole group (data shown as mean ± standard deviation). However, the mean age according to gender was 44.9 ± 18.1 years for males and

Dysphagia also frequently occurs in elderly patients, for which four mechanisms have been proposed: increased rigidity of the trachea leading to easy compression of esophagus, aneurysm formation, presence of Kommerell's diverticulum, elongation of the aorta, the coexistence of an aberrant artery with a truncus bicaroticus, or a close origin of common carotid

To the angiographer who uses the right axillary, brachial or radial approach to the ascending thoracic aorta, the arteria lusoria is also a clinically important element. The presence of an ARSA is suspected in cases in which catheterization of the ascending aorta proves difficult. Using the right radial approach, access to the ascending aorta is usually easy [11]. Previous studies indicate that only 60% of such cases were successfully performed by transradial approach in the setting of AL [26]. This variant makes the right transradial route difficult to approach the ascending aorta, as it requires the catheter to curve back to reach the aortic root [26, 27]. However, the repeated entry of the guide wire from the right subclavian artery to the descending aorta rather than the ascending aorta should indicate this possibility. Thus, angiography can prove to be very challenging in the presence of an arteria lusoria [11, 26, 27].

Finally, the inferior right recurrent laryngeal nerve is an asymptomatic variation anomaly, which can be an important obstacle and be seriously damaged during cervicotomy, thyroid, and parathyroid surgery. In such cases, the inferior right recurrent laryngeal nerve is a classic risk and must be eliminated by location and routine dissection of the nerve [28–30]. This is of particular importance when the diagnosis concerns an asymptomatic neural anomaly discov-

The literature presents two main classifications of the aberrant right subclavian artery. According to Neuhauser's threefold classification, the first type of arteria lusoria crosses the posterior wall of the esophagus, and this is observed in more than 80% of the cases. In the

ered by dissection or a vascular anomaly whose symptoms are very variable [30].

revealed by the extension of aortic dissection or by peripheral arterial embolism.

54.0 ± 19.6 years for females. This difference was statistically significant [15].

arteries from the arch of the aorta [22–25].

**5. Morphological characteristics**

The diagnosis of arteria lusoria was reported only on anatomical dissection until 1936, when Burckhard Kommerell described the clinical diagnosis of an aberrant right subclavian artery that originated from an aortic diverticulum, later known as Kommerell's diverticulum, in a 65 year-old man who was believed to have stomach cancer [4]. In 1946, Gross was the first to report the surgical treatment of dysphagia lusoria, in a four-month-old infant [34].

The diagnostic modalities available to visualize an arteria lusoria include barium esophagogram, computed tomography (CT), magnetic resonance imaging (MRI), digital subtraction angiography (DSA), endoscopy and endoscopic ultrasound. New advances in CT technology allow even small vascular structures to be visualized in detail. Multidetector computed tomography (MDCTA) is now an established diagnostic test in the evaluation of many vascular diseases [35–39].

Barium contrast examination of the esophagus shows a characteristic, extrinsic, smooth diagonal impression at the level of the third and fourth dorsal vertebra. Lateral or oblique views show the extrinsic impression to be posterior, and in case of arteria lusoria, just above the level of the aortic arch. As dysphagia occurs frequently with ingestion of solid foods, including a barium soaked bread bolus may improve localization of the defect [35].

Digital subtraction angiography gives valuable information regarding AL. It is an invasive procedure and, in contrast to MDCT, has the disadvantage in showing extravascular structures such as the esophagus. It has also been shown that the effective radiation doses in MDCT angiography studies are moderate and even lower than those associated with DSA in a comparable patient group.

CT or MRI (magnetic resonance imaging) angiography has replaced conventional angiography and is the gold standard for the diagnosis. It not only confirms the diagnosis but also helps to exclude aneurysm of the aorta or other associated anomalies and to plan the operation [36–39].

MRI has the advantage of being a noninvasive procedure and the patient is spared the potential risk of intravenous contrast agents. MRI is not as useful as MDCT due to the generation of respiratory and cardiac motion artifacts. Also it is not a preferred method due to its cost and prolonged scan time. Although MR angiography may reveal the presence of a vascular anomaly, the information regarding nonvascular mediastinal structures is insufficient [36–39].

Endoscopy may reveal pulsatile, shelf-like extrinsic compression in the posterior wall of the esophagus, with intact mucosa. Such an area of narrowing is usually located between 20 and 24 cm from the mouth [7].

Endoscopic ultrasound (EUS) can identify an arteria lusoria, as it lies close to the esophagus. EUS is regarded as the most accurate test for the evaluation of the esophageal wall and the surrounding structures, with the incorporation of Doppler technology in modern echoendoscopes allowing particularly accurate examination of adjacent vessels [10].

The combination of MDCT with 3D volume rendering images provides further advantages. These allow not only the depiction of the thoracic vascular anomalies but also more accurate assessment of the diameter, angle, and compressed area of the esophagus and the relationship between the AL with the esophagus and other mediastinal structures. In addition, MDCT is a noninvasive procedure, unlike DSA, and offers easier application and a shorter time requirement than DSA or MRA [36–39].
