SYMPTOMATIC SUBCLAVIAN STEAL SYNDROME 4 DECADES AFTER OPERATION FOR DYSPHAGIA-LUSORIA

Congenital abnormalities of the aortic arch may lead to signs and symp toms of tracheal and esophageal obstruction secondary to a restrictive vascular ring. There are many case reports and monographs concerning the surgical management of dysphagia lusoria. This case provides the f irst example of long-term follow-up of surgical intervention for relie f of dysphagia lusoria. A 45-year-old laborer presented with a several year history of episodic bilateral blindness and a more recent onset of ''drop attacks.'' Notably this patient had presented at the age of 18 months with difficulty breathing and eating since birth. The patien t also had frequent upper respiratory infections and episodes of pneum onia. Workup revealed a right-sided aortic arch with a left ligamentum arteriosum. When he was first seen in our clinic, history and physica l examination revealed claudication and diminished pulses in the left upper extremity. Arteriography and duplex studies confirmed reversal o f flow in the patient's left vertebral artery. The arteriogram demonst rated the presence of a right-sided aortic arch and descending aorta a long with the proximal stump of the previously ligated left subclavian artery. He underwent left carotid to left axillary artery bypass for the treatment of symptomatic subclavian steal syndrome. His symptoms h ave resolved with return of antegrade vertebral flow and the presence of normal pulses in the left arm. Congenital aortic abnormalities that lead to tracheal and esophageal compromise are numerous and varied. S urgical management requires a thorough understanding of the person's a natomy and preoperative planning. The life expectancy of patients with dysphagia lusoria necessitates consideration of the long-term consequ ences of surgical intervention.