An Elegant Solution to a Ruptured Right Aberrant Subclavian
An aberrant right subclavian artery (ARSA) is a common aortic arch anomaly, with an incidence of 0.5-1%. Embryologically, it is caused by regression of the fourth aortic arch between the carotid and subclavian arteries to originate distal to the left subclavian artery origin, coursing behind the oesophagus. Arterioenteric fistula is a rare complication with mortality upwards of 70%.

A 72-year-old man with hypertension presented with haematemesis and a syncopal episode, 1 month after Ivor Lewis esophagectomy for the management of oesophageal squamous cell carcinoma. He had a 23mm × 105mm Boston Scientific oesophageal stent to address an anastomotic stricture and a tracheoesophageal fistula.

CT-angiography demonstrated no active bleeding and an ARSA abutting the esophagus. A hemoglobin drop from 104g/L to 57g/L requiring transfusion of four units of packed red blood cells. He underwent endoscopic evaluation where fresh blood in the oesophageal lumen was found. The oesophageal stent was removed, and this resulted in torrential bleeding from the patient's mouth and endotracheal tube. He had a cardiac arrest and required cardiopulmonary resuscitation. A Sengstaken-Blakemore tube was placed without improvement. Spontaneous return of circulation was achieved after a CRE PRO oesophageal balloon (Boston Scientific, USA) was inflated. The vascular surgery team was contacted, and he was moved to the hybrid-operating suite.

A right brachial artery cutdown to insert a long 12Fr sheath was performed. Diagnostic angiography with the oesophageal balloon deflated demonstrated active bleeding from the ARSA (Figure 2). A tapered GORE-covered iliac stent (16mm × 10mm × 70mm) was deployed from the proximal ARSA across the bleeding point with the oesophageal balloon inflated. The stent was post dilated with a 32mm CODA moulding balloon (Cook Medical). Completion angiography with the oesophageal balloon deflated demonstrated forward flow in the subclavian artery, a patent vertebral artery, and no extravasation of contrast. He was extubated on the next day and commenced on lifelong antibiotics.