Dysphagia Aortica Secondary to a Giant Aortic Aneurysm: An Old Sign Revisited

Dysphagia aortica is a rare cause of dysphagia resulting from external esophageal compression by an ectatic, tortuous, or aneurysmal thoracic aorta. We report a case of a 60-year-old man presenting with progressive dysphagia to solids and significant weight loss. Chest radiography demonstrated mediastinal widening with an enlarged aortic knuckle and deviation of the lower trachea and carina to the right side. A barium swallow revealed smooth narrowing of the mid-esophagus and deviation to the right side secondary to external compression. Computed tomography (CT) of the chest demonstrated a giant partially thrombosed saccular aneurysm arising from the descending thoracic aorta, causing compression and displacement of the esophagus and trachea. Positron emission tomography (PET)-CT demonstrated fluorodeoxyglucose (FDG) uptake in the aneurysmal wall along with metabolically active regional lymph nodes, suggestive of an inflammatory or infective process. Blood cultures were sterile, and lymph node sampling was microbiologically negative. Open surgical repair was advised after a heart-team discussion, but the patient declined intervention. This case highlights the importance of considering thoracic aortic aneurysm (TAA) in elderly patients presenting with dysphagia, the role of multimodality imaging and multidisciplinary evaluation, and the potentially fatal outcome of an untreated symptomatic TAA.