- Email: [email protected]
Aneurysms of Aberrant Right Subclavian Arteries
824
Mayo Clin Proc, August 1993, Vol 68
LETTERS
these patients. Because the most severe outcomes, such as pulmonary hypertension, although infrequent, can be disabling, thorough documentation of these complications of EMS will lead to a better understanding of this disorder. Rossanne M. Philen; M.D., M.S. Health Studies Branch Division of Environmental Hazards and Health Effects Robert H. Hill, Jr., Ph.D. Toxicology Branch Division of Environmental Health Laboratory Science
by Knight and Codd' had hematemesis as the initial manifesting symptom, a factor that suggests rupture into the adjacent esophagus. We observed a fatal arterial-esophageal fistula in a 74year-old man with an aneurysm in the aberrant retroesophageal right subclavian artery.' Before this fatal event, the patient had a "sentinel" esophageal hemorrhage. We wish to emphasize that esophageal hemorrhage may be an initial manifesting symptom in patients with aneurysms that involve an anomalous right subclavian artery. Moreover, an initial nonfatal hemorrhage may herald massive fatal hematemesis. William D. Edwards, M.D. Division of Anatomic Pathology
National Center for Environmental Health Centers for Disease Control and Prevention Atlanta, Georgia REFERENCES I. Abaitua Borda I, Posada de la Paz M. Clinical findings. WHO Reg Publ Eur Ser 1992; 42:27-38 2. Tazelaar HD, Myers JL, Drage CW, King TE Jr, Aguayo S, Colby TV. Pulmonary disease associated with L-tryptophaninduced eosinophilic myalgia syndrome: clinical and pathologic features. Chest 1990; 97:1032-1036 3. Martin RW, Duffy J, EngelAG, Lie IT, Bowles CA, MoyerTP, et a1. The clinical spectrum of the eosinophilia-myalgia syndrome associated with t-tryptophan ingestion. Ann Intern Med 1990; 113:124-134 4. Philen RM, Eidson M, Kilbourne EM, Sewell CM, Voorhees R, New Mexico Eosinophilia-Myalgia Syndrome Study Group. Eosinophilia-myalgia syndrome: a clinical case series of 21 patients. Arch Intern Med 1991; 151:533-537 5. Culpepper RC, Williams RG, Mease PJ, Koepsell TD, Kobayashi 1M. Natural history of the eosinophilia-myalgia syndrome. Ann Intern Med 1991; 115:437-442
Aneurysms of Aberrant Right Subclavian Arteries The case report by Kiernan and colleagues in the May 1993 issue of the Mayo Clinic Proceedings (pages 468 to 474) was a beautiful review of the embryologic, diagnostic, and therapeutic aspects of aneurysms that involve aberrant right subclavian arteries. The authors emphasized the substantial likelihood of aneurysmal rupture and recommended surgical repair, even in patients with asymptomatic disease. Although esophageal indentation and aneurysmal rupture were discussed, the possibility of rupture into the esophagus was not mentioned. Of interest, 4 of the 49 patients assessed
Brooks S. Edwards, M.D. Division of Cardiovascular Diseases and Internal Medicine Mayo Clinic Rochester Rochester, Minnesota REFERENCES 1. Knight GC, Codd JE. Anomalous right subclavian artery aneurysms: report of 3 cases, with a review of the literature. Tex HeartInstJ 1991; 18:209-218 2. Edwards BS, Edwards WD, Connolly DC, Edwards JE. Arterial-esophageal fistulae developing in patients with anomalies of the aortic arch system. Chest 1984; 86:732-735.
Dr. Kiernan replies My colleagues and I appreciate the complimentary comments of Drs. Edwards and Edwards and their emphasis on the possibility of "sentinel" hematemesis as a manifesting complaint. We agree that a timely, aggressive response is indicated to avoid exsanguinating hemorrhage, as with any type of aortic or graft-enteric fistula.' Paul D. Kiernan, M.D. Section of Thoracic Surgery Fairfax Hospital Annandale, Virginia REFERENCE 1. Kiernan PD, Pairolero PC, Hubert JP Jr, Mucha P Jr, Wallace RB. Aortic graft-enteric fistula. Mayo Clin Proc 1980; 55:731-738
Mayo Clin Proc, August 1993, Vol 68
LETTERS
these patients. Because the most severe outcomes, such as pulmonary hypertension, although infrequent, can be disabling, thorough documentation of these complications of EMS will lead to a better understanding of this disorder. Rossanne M. Philen; M.D., M.S. Health Studies Branch Division of Environmental Hazards and Health Effects Robert H. Hill, Jr., Ph.D. Toxicology Branch Division of Environmental Health Laboratory Science
by Knight and Codd' had hematemesis as the initial manifesting symptom, a factor that suggests rupture into the adjacent esophagus. We observed a fatal arterial-esophageal fistula in a 74year-old man with an aneurysm in the aberrant retroesophageal right subclavian artery.' Before this fatal event, the patient had a "sentinel" esophageal hemorrhage. We wish to emphasize that esophageal hemorrhage may be an initial manifesting symptom in patients with aneurysms that involve an anomalous right subclavian artery. Moreover, an initial nonfatal hemorrhage may herald massive fatal hematemesis. William D. Edwards, M.D. Division of Anatomic Pathology
National Center for Environmental Health Centers for Disease Control and Prevention Atlanta, Georgia REFERENCES I. Abaitua Borda I, Posada de la Paz M. Clinical findings. WHO Reg Publ Eur Ser 1992; 42:27-38 2. Tazelaar HD, Myers JL, Drage CW, King TE Jr, Aguayo S, Colby TV. Pulmonary disease associated with L-tryptophaninduced eosinophilic myalgia syndrome: clinical and pathologic features. Chest 1990; 97:1032-1036 3. Martin RW, Duffy J, EngelAG, Lie IT, Bowles CA, MoyerTP, et a1. The clinical spectrum of the eosinophilia-myalgia syndrome associated with t-tryptophan ingestion. Ann Intern Med 1990; 113:124-134 4. Philen RM, Eidson M, Kilbourne EM, Sewell CM, Voorhees R, New Mexico Eosinophilia-Myalgia Syndrome Study Group. Eosinophilia-myalgia syndrome: a clinical case series of 21 patients. Arch Intern Med 1991; 151:533-537 5. Culpepper RC, Williams RG, Mease PJ, Koepsell TD, Kobayashi 1M. Natural history of the eosinophilia-myalgia syndrome. Ann Intern Med 1991; 115:437-442
Aneurysms of Aberrant Right Subclavian Arteries The case report by Kiernan and colleagues in the May 1993 issue of the Mayo Clinic Proceedings (pages 468 to 474) was a beautiful review of the embryologic, diagnostic, and therapeutic aspects of aneurysms that involve aberrant right subclavian arteries. The authors emphasized the substantial likelihood of aneurysmal rupture and recommended surgical repair, even in patients with asymptomatic disease. Although esophageal indentation and aneurysmal rupture were discussed, the possibility of rupture into the esophagus was not mentioned. Of interest, 4 of the 49 patients assessed
Brooks S. Edwards, M.D. Division of Cardiovascular Diseases and Internal Medicine Mayo Clinic Rochester Rochester, Minnesota REFERENCES 1. Knight GC, Codd JE. Anomalous right subclavian artery aneurysms: report of 3 cases, with a review of the literature. Tex HeartInstJ 1991; 18:209-218 2. Edwards BS, Edwards WD, Connolly DC, Edwards JE. Arterial-esophageal fistulae developing in patients with anomalies of the aortic arch system. Chest 1984; 86:732-735.
Dr. Kiernan replies My colleagues and I appreciate the complimentary comments of Drs. Edwards and Edwards and their emphasis on the possibility of "sentinel" hematemesis as a manifesting complaint. We agree that a timely, aggressive response is indicated to avoid exsanguinating hemorrhage, as with any type of aortic or graft-enteric fistula.' Paul D. Kiernan, M.D. Section of Thoracic Surgery Fairfax Hospital Annandale, Virginia REFERENCE 1. Kiernan PD, Pairolero PC, Hubert JP Jr, Mucha P Jr, Wallace RB. Aortic graft-enteric fistula. Mayo Clin Proc 1980; 55:731-738