In a female patient admitted with chest pain who has an aberrant subclavian artery on computed tomography angiography, how does this finding affect her management?

Management of Aberrant Subclavian Artery in a Patient with Chest Pain

Immediate Clinical Impact

An aberrant subclavian artery (ARSA) found incidentally on CTA in a patient with chest pain is almost always a benign anatomical variant that does not require intervention unless specific high-risk features are present. 1

The finding itself does not change the acute management of chest pain—you must still complete the standard cardiac workup to exclude acute coronary syndrome as the primary cause of symptoms 2.

Key Decision Points

1. Assess for High-Risk Features Requiring Intervention

Examine the CTA carefully for these specific findings that would mandate vascular surgery consultation 1:

• Kommerell's diverticulum orifice >3.0 cm 1
• Combined diameter of diverticulum plus adjacent descending aorta >5.0 cm 1
• Aneurysmal dilation of the aberrant vessel 2, 3
• Mural thrombus within the vessel 4
• Evidence of dissection 5, 6

2. Correlate with Symptomatology

Determine if the ARSA could be causing the patient's chest pain 7:

• Dysphagia (difficulty swallowing) is the classic symptom when the retroesophageal ARSA compresses the esophagus 2, 7
• Chest pain that worsens with swallowing suggests dysphagia lusoria 7
• Globus sensation (feeling of lump in throat) 7
• Shortness of breath or respiratory symptoms 1, 3

If chest pain is not associated with swallowing and there are no compressive symptoms, the ARSA is almost certainly incidental and unrelated to the presenting complaint 8.

3. Complete Cardiac Evaluation First

The aberrant subclavian artery does not exclude cardiac ischemia 7:

• Complete the standard chest pain workup including serial troponins, ECGs, and functional testing as indicated by your institution's chest pain protocol 2
• The ARSA is found in 0.5-1.8% of the population and is usually asymptomatic 6, 8
• Most patients with ARSA presenting with chest pain have a cardiac etiology for their symptoms, not the anatomical variant 7

Management Algorithm

If Low-Risk ARSA (No High-Risk Features)

No specific intervention is required 8:

• Document the finding in the medical record 1
• Inform the patient this is a benign anatomical variant present since birth 8
• No follow-up imaging is needed unless symptoms develop 1
• Proceed with standard management of the chest pain based on cardiac workup results 2

If High-Risk ARSA (Any High-Risk Feature Present)

Obtain urgent vascular surgery consultation 2, 1:

• Aneurysmal ARSA with Kommerell's diverticulum meeting size criteria requires surgical resection to prevent rupture, which is potentially lethal 2, 3
• Surgical approach involves resection of the aneurysmal segment and adjacent aorta with graft replacement 2
• Endovascular repair with thoracic endovascular aortic repair (TEVAR) is an alternative option 6

If Symptomatic ARSA (Dysphagia/Compressive Symptoms)

Refer to vascular surgery for evaluation 1:

• Symptomatic patients with dysphagia, respiratory symptoms, or recurrent laryngeal nerve palsy warrant intervention even without meeting size criteria 1
• Surgical decompression relieves symptoms in the majority of cases 2

Critical Procedural Considerations

For Future Cardiac Catheterization

Alert the interventional cardiology team about the ARSA before any transradial procedures 5:

• Right transradial access is relatively contraindicated in patients with ARSA 5
• The aberrant anatomy increases risk of vessel dissection, mediastinal hematoma, and catheter manipulation difficulties 5
• If right radial access is attempted and becomes difficult (prolonged time, guide wire enters descending aorta), abort immediately and use alternative access 5
• Left radial or femoral access is preferred 5

Associated Anatomical Variants

Be aware that ARSA is frequently associated with 8:

• Non-recurrent laryngeal nerve (86.7% of cases) - important for any future neck or thoracic surgery 8
• Other aortic arch variants 6

Common Pitfalls to Avoid

1. Do not assume the ARSA is causing chest pain without compressive symptoms - most patients with ARSA and chest pain have a cardiac cause 7

2. Do not order follow-up imaging for uncomplicated ARSA - this is unnecessary and exposes the patient to radiation and cost without benefit 1

3. Do not proceed with right transradial catheterization without reviewing the CTA - this can cause life-threatening dissection 5

4. Do not miss Kommerell's diverticulum - measure the diverticulum orifice and combined diameters on the CTA as these determine need for intervention 1

Documentation Requirements

In your discharge summary or consultation note, specify 1:

• Presence of ARSA with retroesophageal course
• Presence or absence of Kommerell's diverticulum with measurements
• Presence or absence of aneurysmal dilation, thrombus, or dissection
• Whether the finding is symptomatic or incidental
• Recommendation for vascular surgery follow-up (if high-risk features present) or reassurance (if low-risk)