Can an aberrant right subclavian artery (ARSA) cause any effects?

Can an Aberrant Right Subclavian Artery Cause Symptoms?

Yes, an aberrant right subclavian artery (ARSA) can cause symptoms, though most patients remain asymptomatic and are diagnosed incidentally—when symptoms do occur, they typically involve compression of the esophagus (causing dysphagia) or respiratory structures, and the presence of a Kommerell's diverticulum increases the risk of complications requiring intervention. 1, 2

Clinical Presentation Spectrum

Asymptomatic Presentation (Most Common)

• The majority of patients with ARSA remain completely asymptomatic throughout their lives, with the anomaly discovered incidentally during imaging performed for unrelated reasons 3, 4
• ARSA occurs in approximately 1% of the population, making it the most common aortic arch anomaly 2, 4

Symptomatic Presentation

When symptoms develop, they result from compression of adjacent structures as the aberrant vessel courses behind the esophagus:

Esophageal compression symptoms:

• Progressive dysphagia (difficulty swallowing), termed "dysphagia lusoria," is the most common symptom in adults 1, 5, 6
• Odynophagia (painful swallowing) may occur in severe cases 5
• Symptoms can progress to the point where patients can only tolerate liquids, resulting in significant weight loss and dietary restrictions 5, 7

Respiratory symptoms:

• Shortness of breath, chronic cough, and respiratory distress can occur from tracheal compression 1, 6
• In neonates, life-threatening airway complications may develop 3

Other compression-related symptoms:

• Hoarseness from recurrent laryngeal nerve compression (Ortner's syndrome) 1, 8
• Chest pain, pressure, fatigue, or neck/jaw/back pain 8

Critical Associated Finding: Kommerell's Diverticulum

A Kommerell's diverticulum is present in 20-60% of patients with ARSA and significantly impacts management decisions 1, 2:

• This represents a persistent remnant of the fourth primitive dorsal aortic arch 2
• It increases the risk of thoracic aortic aneurysm formation (2-8% of ARSA cases) 2, 8
• The diverticulum itself can contribute to compression symptoms 5, 4

When to Pursue Evaluation

All patients discovered to have an ARSA should undergo dedicated thoracic aortic imaging with CT or MRI to assess for associated aneurysmal disease and Kommerell's diverticulum 2, 8:

Key measurements to obtain:

• The diverticulum orifice diameter (measured radially and longitudinally at the aortic wall) 2
• The combined diameter of the diverticulum and adjacent descending thoracic aorta (measured from the tip of the diverticulum to the opposite aortic wall) 2

Indications for intervention:

Surgical or endovascular intervention is recommended when: 1, 2

• Kommerell's diverticulum orifice is >3.0 cm
• Combined diameter of the diverticulum and adjacent descending aorta is >5.0 cm
• Patient is symptomatic with dysphagia, respiratory symptoms, or recurrent laryngeal nerve palsy

Management Algorithm

For Asymptomatic Patients with Normal Anatomy:

• No intervention required, but initial comprehensive imaging is reasonable to exclude associated aneurysmal disease 2
• Regular surveillance imaging if Kommerell's diverticulum is present but below size thresholds 8

For Symptomatic Patients:

• CT angiography is the test of choice for detailed anatomic assessment 1
• Surgical correction involves ligation and excision of the retroesophageal artery segment with carotid-subclavian bypass 5, 7
• Conservative management may be appropriate for mild, non-progressive symptoms without malnutrition 6

For Patients Meeting Size Criteria:

• Intervention should be considered even in asymptomatic patients when diverticulum measurements exceed thresholds 2
• Choice between open surgical and endovascular approaches depends on patient anatomy, comorbidities, and institutional expertise 2

Important Clinical Pitfalls

Be aware of associated anatomical anomalies that impact surgical approach: 7

• Non-recurrent right inferior laryngeal nerve (present in 86.7% of cases) 4
• Common origin of the common carotid arteries 7
• Aberrant right thoracic duct 7
• Replaced vertebral arteries 7

The severity of symptoms does not always correlate with radiologic findings—some patients with significant anatomic compression remain minimally symptomatic, while others with less dramatic imaging findings experience severe dysphagia 6. This underscores the importance of individualized assessment rather than relying solely on imaging appearance.