Life-threatening Carotid Complications Caused by Extraluminal Migration of Ingested Foreign Bodies; a Case Report and Narrative Review of Literature

Abstract

Carotid complications resulting from extra-luminal migration of ingested foreign bodies (FB) are rare but potentially life-threatening. Previous data on the topic predominantly comprises isolated case reports, leaving a gap in comprehensive evidence necessary to guide clinical decision-making. In this article, we offer a narrative review alongside a novel case report, aimed at providing a broad, evidence-based perspective on the topic to guide clinical practice. The search strategy employed keywords related to carotid artery complications from ingested FB across the following electronic databases: PubMed, Scopus, Google Scholar, and Cochrane Central. Screening involved standardized data extraction by two independent reviewers, with a focus on abstracts meeting inclusion criteria and excluding non-English literature and non-relevant studies from further analysis. Moreover, we present a novel case report on the topic that was successfully managed using a unique surgical approach. Overall, a total of sixteen case reports were finally included, data on clinical presentations, diagnostic strategies and findings, surgical management and outcome were extracted, tabulated, and discussed. In carotid complications from extra-luminal migration of ingested FB, high clinical suspicion is crucial due to potentially mild symptoms and negative first-level examinations. Computed tomography (CT) scan plays a pivotal role for accurate diagnosis and surgical planning, along with neck ultrasound to detect complications. Tailored surgical strategies based on the severity of carotid involvement, including venous patch grafts in severe vessels involvement, are crucial for optimal patient outcomes. As a novelty, in our case report, carotid shunt was successfully employed instead of prolonged carotid clamping to reduce the risk of associated neurological sequelae. It could be concluded that, diagnosis and managing carotid complications from extra-luminal migration of ingested FB remains challenging and a multidisciplinary approach is warranted.

Keywords: Anastomosis; Carotid arteries; Eating; Lacerations; Foreign bodies; surgical.

Figure 1

Neck B-mode ultrasound. (A) Paraxial view using a high-resolution multifrequency linear probe (bandwidth 3-12 MHz). The fish bone passes from the soft tissue posterior to the right lobe of the thyroid to the common carotid artery, where it forms a pseudoaneurysm at the site of entry. A foreign body is seen as a hyper-echoic linear structure within the common carotid artery. Ultrasound machine: Logiq S-8, General Electric, Milwaukee. (B and C) Axial ultrasound view in B-mode (B) and B-mode color Doppler (C) showing a pseudoaneurysm on the medial side of the right common carotid artery. T: thyroid gland; Fb: foreign body; Ps: pseudoaneurysm; C.a.: common carotid artery.

Figure 2

(A) Cervical computed tomography (CT) scan without contrast. Axial basal view of a CT scan (64 slices Ingenuity, Philips, Eindhoven, Netherlands) before administration of contrast medium. A 3-cm hyperdense fishbone can be observed on the right side, migrated into the soft tissues and right neck vascular bundles. Without administration of iodinate contrast medium, it was not possible to assess which vessel had been involved. Abbreviations: T: Thyroid gland; F.b.: foreign body. (B) Contrast-enhanced computed tomography: arterial and vascular phase. Axial view of a contrast-enhanced CT scan (64 slices Ingenuity, Philips, Eindhoven, Netherlands) in the arterial and vascular phases; maximum intensity projection (MIP) technique with 10 cm thickness. A 3-cm hyperdense fishbone can be observed with the lateral extremity in the common carotid artery, the medial extremity in the neck soft tissue (behind the right thyroid lobe), and the pseudoaneurysm on the medial side of the carotid artery at the point at which the fishbone enters the vessel. (C) Contrast-enhanced CT scan in the coronal plane in the arterial phase. Contrast-enhanced CT scan in the arterial, vascular phase (CT 64 slices; Ingenuity, Philips) after intravenous injection of 80 ml of the nonionic soluble water Iopamiro 370 mg/ml (Bracco, Milan, Italy). A 3-cm hyperdense fish bone can be observed with the lateral extremity in the common carotid artery and the medial extremity in the neck soft tissue. A pseudoaneurysm on the medial side of the carotid artery at the point of fish bone entrance is observed. (A) A coronal view of the right carotid artery was obtained using the MIP technique with a thickness of 10 mm. (B) On the right side, the same CT arterial vascular phase scan was performed using the volume rendering (VR) technique to create a three-dimensional representation of the data. The carotid artery pseudoaneurysm and the fish bone with its medial extremity within the artery are well depicted. Fb: foreign body; Ps.: pseudoaneurysm; C.a.: common carotid artery.

Figure 3

Intraoperative view of the neck dissection. (A) The Pruitt-Inahara F3® Carotid Shunt and the tract of the common carotid artery are visible. (B) Surgically removed accidentally ingested fish bone.