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Dysphagia lusoria: A case study
PAGE 14
JOURNAL OF VASCULAR NURSING
MARCH 2001
Dysphagia lusoria: A case study Ann Whitley, BscN, RN
Dysphagia lusoria is described in the literature as difficulty swallowing because of a “jest of nature.” The “jest of nature” is a birth defect encompassing any aortic root vascular anomaly that causes esophageal dysphagia. Persons with dysphagia lusoria can be categorized according to their specific subclavian anomaly (ie, depending on the presence of an aneurysm, occlusive disease, or esophageal compression). All patients with this anomaly have an aberrant subclavian artery in a transposed position that courses posterior to the esophagus. The operative approach to repair this condition has been controversial. An extrathoracic approach is documented as superior to a repair involving thoracotomy because there is decreased rate of complications that may be associated with a thoracotomy and greater visibility of the subclavian and carotid artery. This case study describes a 25-year-old woman with dysphagia lusoria related to an aberrant right subclavian artery. The report includes a literature review and describes the perioperative approach and nursing care. The use of the preadmission and same-day admission services are supported as is an extrathoracic surgical approach. At follow-up this patient reported no symptoms of dysphagia and showed no evidence of esophageal compression confirming that persons with symptomatic dysphagia lusoria can be managed with positive long-term results. (J Vasc Nurs 2001;19:14-9)
Dysphagia lusoria is reportedly the result of esophageal compression by a congenital vascular anomaly.1 Vascular ring and aberrant subclavian artery (aSA) are terms describing the anomaly, which may have any aortic root origin and is most often described as an aberrant right subclavian artery traveling from the left side of the aortic arch and posterior to the esophagus, thus giving the appearance of a ring and causing a squeezing of the esophagus between the aortic arch and the anomalous artery.2 Embryology would suggest that normal anatomy of the great vessels involves the beginning development of 6 paired aortic arches and the subsequent involution of complete arches or a portion of them in the fourth week of fetal life.3 Zamir and Sinclair4 proposed that anomalies of the aortic arch can occur when involution occurs at the incorrect location. An aberrant subclavian artery most likely results from an abnormal interruption of the fourth notch on the aorta and is usually on the right, which is an arch that is destined to disappear.5 Thus the right subclavian artery develops as the last branch of the aortic arch and is in a transposed position. In 1994, Kieffer et al6 classified 4 groups of patients with this vascular anomaly (Figure 1). Group 1 Patients with dysphagia caused by nonaneurysmal aSA Group 2 Patients with symptomatic occlusive disease of nonaneurysmal aSA
Ann Whitley, BscN, RN, is staff nurse, London Health Sciences Centre, Division of Vascular Surgery, London, Ontario, Canada. Address reprint requests to Ann Whitley, 18 Mountsfield Dr, London, Ontario, Canada N6C 2S5. Copyright © 2001 by the Society for Vascular Nursing, Inc. 1062-0303/2001/$35.00 + 0 40/1/113884 doi:10.1067/mvn.2001.113884
Group 3 Patients with aneurysmal aSA without aortic lesions, with or without esophageal compression or arterial thromboembolism Group 4 Patients with an aortic (usually aneurysmal) lesion involving the origin of the aSA with or without aSA aneurysm
CASE REPORT The patient was a 25-year-old woman who presented with symptoms of dysphagia lusoria. A look at her history would suggest that her symptoms had progressed since infancy and childhood. As an infant and child, she experienced repeated colds and chest infections, was very slow to feed, and had frequent episodes of choking, particularly when solid foods were introduced to her diet. She occasionally felt a pins and needles sensation and tingling fingers that seemed to have no precipitating cause. As a young adult, she had increasing intolerance of solid foods, so much so that she preferred fluids and soft food. Meal time was a slow process taken only once a day and not usually in public places. Her condition had affected her social life. She felt stigmatized by her inability to gain weight and her underweight appearance. She was reluctant to attend social gatherings because of her intolerance of solid food and frequent episodes of choking. The patient was troubled by frequent colds, chest infections, chronic bronchitis, and more recently, an 8-month history of a full sensation in her neck. She went to see her family medical doctor because of her complaints. The patient’s relevant health history included a previous history of scoliosis with L4-5 discectomy, breast lumpectomy (benign cystic), and stress-associated pseudo seizures. Her preoperative weight was 47.2 kg (104 lb.), which would suggest a low weight for her height of 164 cm (5 ft, 4 in). Her family history included hypertension, cardiac disease, and stroke.
Vol. XIX
No. 1
JOURNAL OF VASCULAR NURSING
PAGE 15
Figure 2. Thoracic aortic angiogram depicting aberrant right subclavian artery.
Figure 1. Classification into 4 groups of patients with aberrant subclavian arteries. Reprinted with permission from Aberrant subclavian artery: surgical treatment in thirty-three adult patients. Journal of Vascular Surgery 1994;19:101. Copyright © 1994, Mosby.
The patient’s medication use was occasional Fluticasone Propionate (flovent) and a daily birth control pill. Aberrant subclavian artery was confirmed by computed axial tomography and the patient was referred to our center for operative repair.
DIAGNOSIS Diagnostic testing for dysphagia lusoria will vary according to patient complaints. Aberrant subclavian artery may be seen on routine thoracic radiographs, thoracic angiograms, computed axial tomography, or magnetic resonance imaging. In this particular case, a barium swallow was inconclusive. Aberrant subclavian artery was identified on computed axial tomography and confirmed by thoracic aortic angiogram. Figure 2 shows the aberrant subclavian artery on thoracic aortic angiogram. Clearly, the right subclavian artery is in a transposed position coming off the left of the aortic arch.
OPERATIVE REPAIR Operative repair is the only treatment plan for a person with symptomatic dysphagia lusoria. The goal of operative repair is to relieve the dysphagia that is caused by the aberrant artery and to restore circulation. Restoration of normal circulation to the right arm is of utmost importance to prevent possible complications of claudication and subclavian steal syndrome. This is accomplished by anastomosis of the divided subclavian artery to the
Figure 3. Preoperative and postoperative anatomy. Reprinted with permission from Dysphagia lusoria: extrathoracic surgical management. Canadian Journal of Surgery 1996;39:48-52. Copyright © 1996, Canadian Medical Association.
right common carotid artery or directly to the aortic arch with a prosthetic graft.7 There is no standard approach to repair this anomaly. Right and left thoracotomies, cervical incision, median sternotomy, and combination approaches have been used. Thoracotomy is described as the traditional approach for reimplantation or proximal ligation of an aberrant artery; however, an extrathoracic approach has been used. In 1972, Orvald et al8 described the aberrant right subclavian artery as most often coursing high in the mediastinum and being accessible through an incision in the cervical area. For this patient, aberrant right subclavian artery was successfully repaired with a single supra clavicular incision. The subclavian artery was divided approximately 1 cm distal to the aortic arch. The proximal portion was oversewn and the distal portion anastomosed to the carotid artery (Figure 3).
PAGE 16
JOURNAL OF VASCULAR NURSING
MARCH 2001
Figure 4. Clinical pathway.
CLINICAL PATHWAY AND IMPLICATION FOR NURSES Nurses play an important role in the care of patients with dysphagia lusoria. Preoperative teaching that identifies the risk factors, operative procedure, and expected outcome is imperative. When a single incision operative approach is planned, the patient must be informed that in the event of complications a second incision (thoracotomy) and possible heart-lung bypass may be required. Patients with this condition are often underweight and poorly nourished. The operating room nurse provides safety and protection of the skin tissue and bony prominences during the operative procedure. Postoperatively, the neurologic status and vascular status of the right arm is monitored along with the vital signs, respiratory status, fluid balance, wound, integumentary, and patient comfort. Patients are usually discharged within 48 hours after the operation. Before discharge, instructions are given for care of the wound, activity, and medical follow-up (Figure 4).
FOLLOW-UP At 1-month follow-up, the patient reported being free of symptoms. She is tolerating a full diet including meat and has no complaints of dysphagia. She also reported an 8.8 kg (4 lb) weight gain. She has no complaints of weakness or paresthesia in the right arm, and nerve testing performed 3 weeks after surgical repair confirmed no nerve damage. Blood pressure and pulse is equal in both arms. Her right supraclavicular wound is healed with minimal scar and no signs or symptoms of infection.
DISCUSSION Dysphagia lusoria is not uncommon; it is reported to be present in 1 in 200 persons.9 In 1794, Bayford10 recognized that aSA may be the cause of trachea compression and dysphagia. In 1946, Gross11 performed the first operation to repair this anomaly. Symptoms of dysphagia lusoria may occur at any age; it is not clear why some patients have dysphagia symptoms in infancy and others do not report symptoms until they are middle- or old-aged. Adults typically present with symptoms of dysphagia; infants more often present with respiratory symptoms. McNally and Rak12 explain that this is so because in adults the esophagus is more apt to be compressed because the trachea is rigid. In infants the trachea is compressible; the typical sign and symptoms are respiratory, such as wheezing, stridor, recurrent pneumonia, and cyanosis. An extrathoracic surgical approach is documented as superior to a repair involving thoracotomy because there is a decreased rate of complications compared with the thoracic approach and greater visibility of the subclavian and carotid artery.2 Valentine et al13 recognized that there was no need for thoracotomy or extensive dissection, advocating a right supraclavicular approach through a single incision to achieve the surgical goals of ligation, reimplantation, and esophageal dilation. In 1996, Taylor et al2 confirmed that point. Kieffer et al6 demonstrated that the surgical approach to aSA repair was varied and classified this anomaly into 4 groups. Radiologic tests, angiogram CT, and magnetic resonance
Vol. XIX
No. 1
JOURNAL OF VASCULAR NURSING
imaging are the diagnostic tools used to identify this anomaly and to plan for patient care and management. Patients with an aberrant subclavian artery that is uncomplicated by aneurysm or aortic involvement can be successfully treated by operative repair with a single supraclavicular approach.
CONCLUSION Dramatic strides have been made in reducing complicated surgeries and lengthy hospital stays. Nurses play a fundamental role in organizing and implementing the care that is required to provide a safe and expeditious perioperative course. This case report demonstrates that by using all available resources including advanced diagnostic and surgical techniques, vascular nursing care, preadmission services, and same-day admission services, optimum quality care can be delivered. Persons with symptomatic dysphagia lusoria can be managed with positive long-term results.
REFERENCES 1. Hunauld FJ. Examen de quelques parties d’un singe. Hist Acad Roy Sci 1738;1:379-81. 2. Taylor M, Harris KA, Casson AG, et al. Dysphagia lusoria: extrathoracic surgical management. Can J Surg 1996; 39:4852. 3. Akers DL, Fowl RJ, Plettner J, et al. Complications of anomalous origin of the right subclavian artery: case report and review of the literature. Ann Vasc Surg 1991;5:385-8.
PAGE 17
4. Zamir M, Sinclair P. Continuum analysis of common branching patterns in the human arch of the aorta. Anat Embryol 1990;181:31-6. 5. Stewart JR, Kincaid OW, Edwards JE. An atlas of vascular rings and related malformations of the aortic arch system. Springfield (IL): Charles C Thomas; 1964. p. 98-123. 6. Kiefer E, Bahnini A, Koskas F. Aberrant subclavian artery: surgical treatment in thirty-three adult patients. J Vasc Surg 1994;19:100-11. 7. Karlson KJ, Heiss FW, Ellis FH. Adult dysphagia lusoria. Treatment by arterial division and reestablishment of vascular continuity. Chest 1985;87:684-6. 8. Orvald TO, Sheerer R, Judge JR. A single cervical approach to aberrant right subclavian artery. Surgery 1972;71:227-30. 9. Edwards JE. Anomalies of the aortic arch system. Birth Defects 1977;13:47-63. 10. Bayford D. Account of a single case of obstructed deglutition. Mem Med Soc London 1794;2:275-85. 11. Gross RE. Surgical treatment for dysphagia lusoria. Ann Surg 1946;124:532-4. 12. McNally PR, Rak KM. Dysphagia lusoria caused by persistent right aortic arch with aberrant left subclavian artery and diverticulum of kommerell. Dig Dis Sci 1992;37:144-9. 13. Valentine RJ, Carter DJ, Clagett GP. A modified extrathoracic approach to the treatment of dysphagia lusoria. J Vasc Surg 1987;5:498-500.
WRITING AWARD The Journal of Vascular Nursing Article Award honors nurse authors for their efforts to create a publishable manuscript. Manuscripts will be judged for accuracy of content, relevance to vascular nursing practice, and excellence of writing style. All feature articles published in the Journal of Vascular Nursing during the calendar year will be considered for the JVN Article Award. The award recipient will be given a plaque commemorating the award and a cash prize donated by Mosby. The award and cash prize will presented at the annual symposium. Annoucement of the award recipient will appear in the Journal of Vascular Nursing and in SVN...prn.
PAGE 18
JOURNAL OF VASCULAR NURSING
MARCH 2001
Dysphagia lusoria: A case study Contact Hours: 1.0
Minimum Passing Score: 70%
Test ID: JVN2301
Test Processing Fee: $10.00
OBJECTIVES:
1. Describe the pathophysiology of dysphagia lusoria. 2. Discuss the clinical pathway for dysphagia lusoria. 3. Identify nursing implications for clients with dysphagia lusoria.
1. What structure is compressed with dysphagia lusoria? a. aorta b. esophagus c. subclavian artery d. left carotid artery 2. Operative repair for symptomatic dysphagia lusoria includes restoring circulation to: a. right arm b. left arm c. right leg d. left leg 3. A complication of surgical repair of dysphagia lusoria could include: a. amputation b. lobectomy c. heart-lung bypass d. none of the above 4. On follow-up, it is important to check for all of the following EXCEPT: a. weight b. paraesthesia c. nerve testing of arms d. pulse rate 5. Respiratory symptoms are the most common complaint of dysphagia lusoria in which patients? a. infants b. young adults c. adults d. elderly 6. Which of the following is NOT used as a diagnostic tool for dysphagia lusoria? a. CT b. MRI
c. auscultations d. angiogram 7. When should the patient be admitted to the hospital prior to surgery? a. same day b. 24 hours before c. 3 days before d. varies 8. In the PACU, besides the radial pulse, which other vital sign is checked? a. pedal pulses b. temporal pulse c. apical pulse d. femoral pulse 9. Circulation, motion, and sensation checks are done routinely on: a. left arm b. right arm c. left leg d. right leg 10. How soon after surgery is the patient discharged home? a. same day b. 24 hours c. 36 hours d. 48 hours 11. Follow up after surgery for dysphagia lusoria is usually: a. 1 week b. 2 weeks c. 1 month d. 2 months
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No. 1
JOURNAL OF VASCULAR NURSING
PAGE 19
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JOURNAL OF VASCULAR NURSING
MARCH 2001
Dysphagia lusoria: A case study Ann Whitley, BscN, RN
Dysphagia lusoria is described in the literature as difficulty swallowing because of a “jest of nature.” The “jest of nature” is a birth defect encompassing any aortic root vascular anomaly that causes esophageal dysphagia. Persons with dysphagia lusoria can be categorized according to their specific subclavian anomaly (ie, depending on the presence of an aneurysm, occlusive disease, or esophageal compression). All patients with this anomaly have an aberrant subclavian artery in a transposed position that courses posterior to the esophagus. The operative approach to repair this condition has been controversial. An extrathoracic approach is documented as superior to a repair involving thoracotomy because there is decreased rate of complications that may be associated with a thoracotomy and greater visibility of the subclavian and carotid artery. This case study describes a 25-year-old woman with dysphagia lusoria related to an aberrant right subclavian artery. The report includes a literature review and describes the perioperative approach and nursing care. The use of the preadmission and same-day admission services are supported as is an extrathoracic surgical approach. At follow-up this patient reported no symptoms of dysphagia and showed no evidence of esophageal compression confirming that persons with symptomatic dysphagia lusoria can be managed with positive long-term results. (J Vasc Nurs 2001;19:14-9)
Dysphagia lusoria is reportedly the result of esophageal compression by a congenital vascular anomaly.1 Vascular ring and aberrant subclavian artery (aSA) are terms describing the anomaly, which may have any aortic root origin and is most often described as an aberrant right subclavian artery traveling from the left side of the aortic arch and posterior to the esophagus, thus giving the appearance of a ring and causing a squeezing of the esophagus between the aortic arch and the anomalous artery.2 Embryology would suggest that normal anatomy of the great vessels involves the beginning development of 6 paired aortic arches and the subsequent involution of complete arches or a portion of them in the fourth week of fetal life.3 Zamir and Sinclair4 proposed that anomalies of the aortic arch can occur when involution occurs at the incorrect location. An aberrant subclavian artery most likely results from an abnormal interruption of the fourth notch on the aorta and is usually on the right, which is an arch that is destined to disappear.5 Thus the right subclavian artery develops as the last branch of the aortic arch and is in a transposed position. In 1994, Kieffer et al6 classified 4 groups of patients with this vascular anomaly (Figure 1). Group 1 Patients with dysphagia caused by nonaneurysmal aSA Group 2 Patients with symptomatic occlusive disease of nonaneurysmal aSA
Ann Whitley, BscN, RN, is staff nurse, London Health Sciences Centre, Division of Vascular Surgery, London, Ontario, Canada. Address reprint requests to Ann Whitley, 18 Mountsfield Dr, London, Ontario, Canada N6C 2S5. Copyright © 2001 by the Society for Vascular Nursing, Inc. 1062-0303/2001/$35.00 + 0 40/1/113884 doi:10.1067/mvn.2001.113884
Group 3 Patients with aneurysmal aSA without aortic lesions, with or without esophageal compression or arterial thromboembolism Group 4 Patients with an aortic (usually aneurysmal) lesion involving the origin of the aSA with or without aSA aneurysm
CASE REPORT The patient was a 25-year-old woman who presented with symptoms of dysphagia lusoria. A look at her history would suggest that her symptoms had progressed since infancy and childhood. As an infant and child, she experienced repeated colds and chest infections, was very slow to feed, and had frequent episodes of choking, particularly when solid foods were introduced to her diet. She occasionally felt a pins and needles sensation and tingling fingers that seemed to have no precipitating cause. As a young adult, she had increasing intolerance of solid foods, so much so that she preferred fluids and soft food. Meal time was a slow process taken only once a day and not usually in public places. Her condition had affected her social life. She felt stigmatized by her inability to gain weight and her underweight appearance. She was reluctant to attend social gatherings because of her intolerance of solid food and frequent episodes of choking. The patient was troubled by frequent colds, chest infections, chronic bronchitis, and more recently, an 8-month history of a full sensation in her neck. She went to see her family medical doctor because of her complaints. The patient’s relevant health history included a previous history of scoliosis with L4-5 discectomy, breast lumpectomy (benign cystic), and stress-associated pseudo seizures. Her preoperative weight was 47.2 kg (104 lb.), which would suggest a low weight for her height of 164 cm (5 ft, 4 in). Her family history included hypertension, cardiac disease, and stroke.
Vol. XIX
No. 1
JOURNAL OF VASCULAR NURSING
PAGE 15
Figure 2. Thoracic aortic angiogram depicting aberrant right subclavian artery.
Figure 1. Classification into 4 groups of patients with aberrant subclavian arteries. Reprinted with permission from Aberrant subclavian artery: surgical treatment in thirty-three adult patients. Journal of Vascular Surgery 1994;19:101. Copyright © 1994, Mosby.
The patient’s medication use was occasional Fluticasone Propionate (flovent) and a daily birth control pill. Aberrant subclavian artery was confirmed by computed axial tomography and the patient was referred to our center for operative repair.
DIAGNOSIS Diagnostic testing for dysphagia lusoria will vary according to patient complaints. Aberrant subclavian artery may be seen on routine thoracic radiographs, thoracic angiograms, computed axial tomography, or magnetic resonance imaging. In this particular case, a barium swallow was inconclusive. Aberrant subclavian artery was identified on computed axial tomography and confirmed by thoracic aortic angiogram. Figure 2 shows the aberrant subclavian artery on thoracic aortic angiogram. Clearly, the right subclavian artery is in a transposed position coming off the left of the aortic arch.
OPERATIVE REPAIR Operative repair is the only treatment plan for a person with symptomatic dysphagia lusoria. The goal of operative repair is to relieve the dysphagia that is caused by the aberrant artery and to restore circulation. Restoration of normal circulation to the right arm is of utmost importance to prevent possible complications of claudication and subclavian steal syndrome. This is accomplished by anastomosis of the divided subclavian artery to the
Figure 3. Preoperative and postoperative anatomy. Reprinted with permission from Dysphagia lusoria: extrathoracic surgical management. Canadian Journal of Surgery 1996;39:48-52. Copyright © 1996, Canadian Medical Association.
right common carotid artery or directly to the aortic arch with a prosthetic graft.7 There is no standard approach to repair this anomaly. Right and left thoracotomies, cervical incision, median sternotomy, and combination approaches have been used. Thoracotomy is described as the traditional approach for reimplantation or proximal ligation of an aberrant artery; however, an extrathoracic approach has been used. In 1972, Orvald et al8 described the aberrant right subclavian artery as most often coursing high in the mediastinum and being accessible through an incision in the cervical area. For this patient, aberrant right subclavian artery was successfully repaired with a single supra clavicular incision. The subclavian artery was divided approximately 1 cm distal to the aortic arch. The proximal portion was oversewn and the distal portion anastomosed to the carotid artery (Figure 3).
PAGE 16
JOURNAL OF VASCULAR NURSING
MARCH 2001
Figure 4. Clinical pathway.
CLINICAL PATHWAY AND IMPLICATION FOR NURSES Nurses play an important role in the care of patients with dysphagia lusoria. Preoperative teaching that identifies the risk factors, operative procedure, and expected outcome is imperative. When a single incision operative approach is planned, the patient must be informed that in the event of complications a second incision (thoracotomy) and possible heart-lung bypass may be required. Patients with this condition are often underweight and poorly nourished. The operating room nurse provides safety and protection of the skin tissue and bony prominences during the operative procedure. Postoperatively, the neurologic status and vascular status of the right arm is monitored along with the vital signs, respiratory status, fluid balance, wound, integumentary, and patient comfort. Patients are usually discharged within 48 hours after the operation. Before discharge, instructions are given for care of the wound, activity, and medical follow-up (Figure 4).
FOLLOW-UP At 1-month follow-up, the patient reported being free of symptoms. She is tolerating a full diet including meat and has no complaints of dysphagia. She also reported an 8.8 kg (4 lb) weight gain. She has no complaints of weakness or paresthesia in the right arm, and nerve testing performed 3 weeks after surgical repair confirmed no nerve damage. Blood pressure and pulse is equal in both arms. Her right supraclavicular wound is healed with minimal scar and no signs or symptoms of infection.
DISCUSSION Dysphagia lusoria is not uncommon; it is reported to be present in 1 in 200 persons.9 In 1794, Bayford10 recognized that aSA may be the cause of trachea compression and dysphagia. In 1946, Gross11 performed the first operation to repair this anomaly. Symptoms of dysphagia lusoria may occur at any age; it is not clear why some patients have dysphagia symptoms in infancy and others do not report symptoms until they are middle- or old-aged. Adults typically present with symptoms of dysphagia; infants more often present with respiratory symptoms. McNally and Rak12 explain that this is so because in adults the esophagus is more apt to be compressed because the trachea is rigid. In infants the trachea is compressible; the typical sign and symptoms are respiratory, such as wheezing, stridor, recurrent pneumonia, and cyanosis. An extrathoracic surgical approach is documented as superior to a repair involving thoracotomy because there is a decreased rate of complications compared with the thoracic approach and greater visibility of the subclavian and carotid artery.2 Valentine et al13 recognized that there was no need for thoracotomy or extensive dissection, advocating a right supraclavicular approach through a single incision to achieve the surgical goals of ligation, reimplantation, and esophageal dilation. In 1996, Taylor et al2 confirmed that point. Kieffer et al6 demonstrated that the surgical approach to aSA repair was varied and classified this anomaly into 4 groups. Radiologic tests, angiogram CT, and magnetic resonance
Vol. XIX
No. 1
JOURNAL OF VASCULAR NURSING
imaging are the diagnostic tools used to identify this anomaly and to plan for patient care and management. Patients with an aberrant subclavian artery that is uncomplicated by aneurysm or aortic involvement can be successfully treated by operative repair with a single supraclavicular approach.
CONCLUSION Dramatic strides have been made in reducing complicated surgeries and lengthy hospital stays. Nurses play a fundamental role in organizing and implementing the care that is required to provide a safe and expeditious perioperative course. This case report demonstrates that by using all available resources including advanced diagnostic and surgical techniques, vascular nursing care, preadmission services, and same-day admission services, optimum quality care can be delivered. Persons with symptomatic dysphagia lusoria can be managed with positive long-term results.
REFERENCES 1. Hunauld FJ. Examen de quelques parties d’un singe. Hist Acad Roy Sci 1738;1:379-81. 2. Taylor M, Harris KA, Casson AG, et al. Dysphagia lusoria: extrathoracic surgical management. Can J Surg 1996; 39:4852. 3. Akers DL, Fowl RJ, Plettner J, et al. Complications of anomalous origin of the right subclavian artery: case report and review of the literature. Ann Vasc Surg 1991;5:385-8.
PAGE 17
4. Zamir M, Sinclair P. Continuum analysis of common branching patterns in the human arch of the aorta. Anat Embryol 1990;181:31-6. 5. Stewart JR, Kincaid OW, Edwards JE. An atlas of vascular rings and related malformations of the aortic arch system. Springfield (IL): Charles C Thomas; 1964. p. 98-123. 6. Kiefer E, Bahnini A, Koskas F. Aberrant subclavian artery: surgical treatment in thirty-three adult patients. J Vasc Surg 1994;19:100-11. 7. Karlson KJ, Heiss FW, Ellis FH. Adult dysphagia lusoria. Treatment by arterial division and reestablishment of vascular continuity. Chest 1985;87:684-6. 8. Orvald TO, Sheerer R, Judge JR. A single cervical approach to aberrant right subclavian artery. Surgery 1972;71:227-30. 9. Edwards JE. Anomalies of the aortic arch system. Birth Defects 1977;13:47-63. 10. Bayford D. Account of a single case of obstructed deglutition. Mem Med Soc London 1794;2:275-85. 11. Gross RE. Surgical treatment for dysphagia lusoria. Ann Surg 1946;124:532-4. 12. McNally PR, Rak KM. Dysphagia lusoria caused by persistent right aortic arch with aberrant left subclavian artery and diverticulum of kommerell. Dig Dis Sci 1992;37:144-9. 13. Valentine RJ, Carter DJ, Clagett GP. A modified extrathoracic approach to the treatment of dysphagia lusoria. J Vasc Surg 1987;5:498-500.
WRITING AWARD The Journal of Vascular Nursing Article Award honors nurse authors for their efforts to create a publishable manuscript. Manuscripts will be judged for accuracy of content, relevance to vascular nursing practice, and excellence of writing style. All feature articles published in the Journal of Vascular Nursing during the calendar year will be considered for the JVN Article Award. The award recipient will be given a plaque commemorating the award and a cash prize donated by Mosby. The award and cash prize will presented at the annual symposium. Annoucement of the award recipient will appear in the Journal of Vascular Nursing and in SVN...prn.
PAGE 18
JOURNAL OF VASCULAR NURSING
MARCH 2001
Dysphagia lusoria: A case study Contact Hours: 1.0
Minimum Passing Score: 70%
Test ID: JVN2301
Test Processing Fee: $10.00
OBJECTIVES:
1. Describe the pathophysiology of dysphagia lusoria. 2. Discuss the clinical pathway for dysphagia lusoria. 3. Identify nursing implications for clients with dysphagia lusoria.
1. What structure is compressed with dysphagia lusoria? a. aorta b. esophagus c. subclavian artery d. left carotid artery 2. Operative repair for symptomatic dysphagia lusoria includes restoring circulation to: a. right arm b. left arm c. right leg d. left leg 3. A complication of surgical repair of dysphagia lusoria could include: a. amputation b. lobectomy c. heart-lung bypass d. none of the above 4. On follow-up, it is important to check for all of the following EXCEPT: a. weight b. paraesthesia c. nerve testing of arms d. pulse rate 5. Respiratory symptoms are the most common complaint of dysphagia lusoria in which patients? a. infants b. young adults c. adults d. elderly 6. Which of the following is NOT used as a diagnostic tool for dysphagia lusoria? a. CT b. MRI
c. auscultations d. angiogram 7. When should the patient be admitted to the hospital prior to surgery? a. same day b. 24 hours before c. 3 days before d. varies 8. In the PACU, besides the radial pulse, which other vital sign is checked? a. pedal pulses b. temporal pulse c. apical pulse d. femoral pulse 9. Circulation, motion, and sensation checks are done routinely on: a. left arm b. right arm c. left leg d. right leg 10. How soon after surgery is the patient discharged home? a. same day b. 24 hours c. 36 hours d. 48 hours 11. Follow up after surgery for dysphagia lusoria is usually: a. 1 week b. 2 weeks c. 1 month d. 2 months
Vol. XIX
No. 1
JOURNAL OF VASCULAR NURSING
PAGE 19
Nursing Continuing Education Answer/Enrollment Form JOURNAL OF VASCULAR NURSING Test ID#: JVN 2301 Minimum Passing Score: 70%
Title: Dysphagia lusoria: A case study Contact Hours: 1.0
To receive CE credits, 1. Read the article, then answer the questions (There is only one right answer for each question). 2. Include the test processing fee of $10 with this answer form.
Make checks payable to BUCHANAN & ASSOCIATES (You may duplicate this answer form.)
3. Mail to: Buchanan & Associates, 1666 Garnet Ave #102, San Diego, CA 92109 You should receive your certificate within 3 weeks of mailing. Call 800.929.1233 or www.nursingce.com
Name: (please print) First
RN License#: M.I.
Last
Mailing Address:
City:
Phone:
State:
Zip:
Soc Sec#:
ANSWERS: 1
6
11
16
2 3
7 8
12 13
17 18
4
9
14
19
5
10
15
20
How long did it take you to complete this program? Check the appropriate box
1/2-1 hour
1-1 1/2 hrs
1 1/2-2 hrs
2 hrs or more
Please evaluate the program using the following criteria. The course was able to meet the objectives and they were related to the overall purpose and goals of this program
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree* (comments)
The objectives were related to the goals of this program Objective #1 Objective #2 Objective #3 Objective #4 The information presented was accurate, current and at an appropriate educational level for this audience The teaching method was appropriate and effective for the material presented This program met my personal professional educational needs as it relates to this topic The information presented was relevant to my practice The teaching methodology (didactic) was appropriate to the material presented This form of continuing education was appropriate to the subject matter You may also submit the evaluation form to your local board of nursing in addition to Buchanan & Associates Comments and suggestions for future topics:
Buchanan & Associates is accredited as a provider of continuing education in nursing by the: American Nurses Credentialing Center, Commission on Accreditation, California Board of Registered Nursing CEP# 9473, Florida Board of Nursing FBN 2159.