Dr. Ch Venkat Kumar Raju, Dr. Sajith Kesavan, Dr.C Jayakumar
Department of pediatrics
Amrita institute of medical sciences, Kochi
7-month-old male child was brought with complaints of recurrent wheeze and frequent coughing while feeding since 6 weeks of age. Child was admitted multiple time from 6 weeks of age was diagnosed to have recurrent LRTI and wheeze refractory to bronchodilators and inhaled corticosteroids. Mother gives a history of coughing while feeding mostly semi solid contents followed . Non projectile non bilious vomiting. Child was on PPIs (Lansoprazole) since last 4 months and domperidone since a month. ECHO was done outside was normal. As there was no improvement in symptoms child was brought to our institute for further evaluation and management.
Relevant past history- Child was 3rd of Non consanguineous marriage, preterm at 34 weeks, Birth weight of 2.2kg and was in NICU for 4 days.
At admission- Vitals were stable, pulse and BP was normal, no signs of respiratory distress Auscultation revealed bilateral wheeze
At this point our differentials were
1. Reactive airway disease
2. Recurrent Aspiration pneumonia
3. Foreign body aspiration
4. Congenital airway anomalies
5. Cystic fibrosis
6. Immunodeficiency or Ciliary dyskinesias
7. Vascular anomalies
Bronchoscopy was done which showed mild narrowing of trachea on the right half of mid trachea with anterior pulpability. Hence a CT pulmonary angiogram was done which showed an aberrant right subclavian artery seen coursing posterior to esophagus from left to right. Indenting the anterior esophageal wall. At this level the AP diameter of trachea is mildly narrowed. The child was diagnosed to have a left aortic arch and right aberrant subclavian artery.
The CT image shows the aberrant artery with esophageal and tracheal compression
Above picture shows barium swallow – external indentation in the posterior wall of esophagus at the level of aortic arch.
Child is currently under routine follow up. As of now no active intervention was not planned.
Aberrant Subclavian Artery in Pediatrics
Overview
An aberrant subclavian artery (ASA) is a rare anatomical variant where the subclavian artery arises abnormally from the aortic arch. The right subclavian artery (ARSA) typically arises as the last branch of the aortic arch and travels behind the esophagus. This anomaly is often congenital and results from aberrant embryological development.
Clinical Presentation
• Asymptomatic: Many children with ASA are asymptomatic, and the condition is often discovered incidentally during imaging for other reasons.
• Symptomatic: Symptoms can include:
o Dysphagia (Dysphagia Lusoria): Difficulty swallowing due to esophageal compression.
o Respiratory Issues: Stridor or wheezing due to tracheal compression.
o Chest Pain: Less common, but can occur due to vascular compression.
Diagnosis
• Barium Swallow: Reveals posterior esophagealindentation, suggesting ARSA.
• CT/MRI Angiography: Provides a detailed view of vascular structures, confirming the presence and course of the aberrant artery.
• Ultrasound: Non-invasive and useful in infants and young children to assess vascular anomalies.
Management
• Asymptomatic Children: Typically monitored with periodic follow-up to check for the development of symptoms.
• Symptomatic Children: Interventions may include:
o Surgical Repair: To reposition the artery and relieve compression.
o Endovascular Procedures: Less invasive methods to correct the vascular anomaly.
o Symptomatic Relief: Management of symptoms such as dysphagia or respiratory issues through supportive care and specific treatments.
Take home message –
With appropriate management, most children with ASA can lead normal, healthy lives. Early detection and intervention, especially in symptomatic cases, are crucial for optimal outcomes.