Fistula Formation Between An Aberrant Right Subclavian Artery and Esophagus with Fatal Bleeding ________________________________________

Abstract

Background:  An aberrant right subclavian artery (ARSA) is a common aortic arch anomaly. Fistula formation between ARSA and esophagus is a rare complication with high mortality rate.
Case presentation: We describe the case of a 34-year-old man - ICU patient, who developed massive bleeding from the upper gastrointestinal (GI) tract. Due to hemorrhagic shock and hypotension hemorrhage was spontaneously stopped that’s why bleeding lesion was not detected on twice performed upper GI endoscopy. Small (5x6 mm) voluminous non-hemorrhagic formation was revealed in the proximal third of the esophagus. An emergency laparotomy, gastrotomy was performed. No bleeding was observed from the stomach and duodenum. Upper GI endoscopy was performed again during the operation.  Active arterial bleeding from a volumetric formation in the upper third of the esophagus was observed. Bleeding was stopped by inserting a Sengstaken-Blakemore tube. After resuscitation the patient underwent a chest CT angiography. Aberrant right subclavian artery - esophageal fistula was detected. Successful control of the bleeding was accomplished. It is conceivable that prolonged nasogastric tube standing (42 days) was the cause of fistula formation. Further treatment was planned, but he experienced a cardiopulmonary arrest and died despite resuscitative efforts.
Conclusion: Intensive care unit patients should be screened if long-term placement of nasogastric tube is required. If ARSA is diagnosed, the nasogastric tube must be removed and percutaneous endoscopic gastrostomy or feeding jejunostomy should be performed for further nutritional support.