Dysphagia aortica relieved by thoracic endovascular aneurysm repair

An 85-year-old man, with symptoms of sudden new-onset dysphagia 1 day after eating a quail egg, was referred for endoscopic evaluation. The patient presented a history of hypertension and chronic empyema. Esophagogastroduodenoscopy (EGD) revealed an impacted quail egg in the mid-esophagus (Fig. 1A). After removing the egg, pulsatile extrinsic compression was observed on endoscopic examination (Fig. 1B). A coronal view of the chest computed tomography (CT) showed an extraluminal protruding thrombus of the aneurysm in the descending thoracic aorta. The arrow indicates a deviated and compressed esophagus (Fig. 1C). Dysphagia caused by marked aneurysmal dilatation of the aorta is called dysphagia aortica, which is rare. The dilated aneurysmal aorta extrinsically compresses the esophageal lumen against the left atrium, resulting in the mechanical obstruction of the food bolus. In this patient, regarding the deformed thoracic cavity, the coexistence of an aortic aneurysm and chronic empyema might have been associated with the dysphagia aortica progression. He was concerned about recurrent food impaction and presented the risk of an aortic rupture, and thoracic endovascular aneurysm repair (TEVAR) with two metallic stent grafts (36 mm/6 cm, 38 mm/8 cm, Seal Stent graft, S&G Biotec, Yongin, Korea) was performed (Fig. 2A). Esophagography revealed luminal narrowing due to extrinsic compression at the insertion site of the TEVAR (Fig. 2B). Additionally, the patient was managed with dietary modifications and prokinetic agents. Because the patient’s symptoms and imaging findings were consistent with the classical features of dysphagia aortica, esophageal manometry was not performed. Two months after TEVAR, follow-up EGD revealed the esophageal lumen with a slightly dilated diameter (Fig. 2C). The patient showed an improvement in impaired swallowing. Chest CT and dysphagia aortica should be considered as differential diagnoses of dysphagia in the elderly. TEVAR might be a good modality for the treatment of dysphagia aortica. However, this procedure should be decided based on the severity of the symptoms and the patient’s medical condition.

Figure 1

(A) Esophagogastroduodenoscopy shows an impacted quail egg in the mid-esophagus. (B) An endoscopic image shows pulsatile extrinsic compression after the removal of the quail egg. (C) Chest computed tomography shows a deviated and compressed esophagus due to marked aneurysmal dilatation in the descending thoracic aorta (arrow). Chronic loculated effusion with internal air is observed in the left lung.

Figure 2

(A) Chest X-ray reveals thoracic endovascular aneurysm repair (TEVAR) with two metallic stent grafts. (B) Esophagography shows a narrow esophageal lumen due to extrinsic compression at insertion site of TEVAR. (C) Esophagogastroduodenoscopy after 2 months shows the mid-esophageal lumen with a slightly dilated diameter.

Informed consent was obtained from the patient.