An Unusual Presentation of Foreign Body in the Common Carotid Artery

Abstract

Penetrating trauma to neck resulting in arteriovenous (AV) fistula and aneurysms involving the carotid system are uncommon injuries with life-threatening consequences. We report here a case of a young factory worker who developed a traumatic AV fistula with false aneurysm, with however, no other complications. He was successfully operated when he presented to us two months after the injury and is doing well in follow-up.

Introduction

Retained Foreign bodies in the vascular system are mostly clinical procedure related fragmented devices. Some other foreign bodies like fish bone, bone chips, nuts ect. sometimes penetrate into common carotid artery from upper digestive tract. High flying objects like shrapnel, splinters can injure any blood vessels causing profuse bleeding. But a foreign body in the neck gradually eroding into common carotid artery is an extremely rare phenomenon.

Case report

A 25 year old scrap factory worker presented to us with a painless, gradually increasing swelling in the right side of his neck, following injury by a penetrating metallic splinter two months back. He had no other complaints.

He did not give any history of bleeding from the nose or ears, problems with vision or any sensory or motor deficit during this two month period. There was also no history of increasing breathlessness, cough, change in voice.

Local examination revealed a 3 × 2 cm firm, pulsatile swelling in the right side of his neck at the level of the thyroid cartilage. The swelling had a palpable thrill. Examination of the chest revealed normal heart sounds and breath sounds.

His routine blood investigations, chest X-ray, echocardiography were within normal limits.

An X-ray of the neck showed an opaque foreign body in the right side of his neck (Fig. 1). A doppler ultrasound of the neck suggested that there was an AV fistula involving the right common carotid and the internal jugular vein and the foreign body was close to the carotid artery.

Fig. 1.

AP and lateral view X-rays of the neck showing the radio-opaque foreign body

Surgical exploration was undertaken under general anaesthesia. Permissive hypercarbia of the level of etco2 at 50-55 mm Hg with hypertension using inotrope with mean BP of 110-120 mm Hg was used.

The AV fistula was dissected out and after taking proximal and distal control (Fig. 2), then it was excised. Next an attempt was made to localize the foreign body under C-arm guidance. With great difficulty and after careful palpation of the carotid artery, it was localized to the undersurface of the carotid artery at the level of the thyroid cartilage.

Fig. 2.

Foreign body seen inside the exposed pseudoaneurysm in the common carotid artery

Palpation also suggested that it was within the vessel. An arteriotomy was done and the splinter was removed from a saccular aneurysm in the posterior wall of the common carotid artery. The aneurysm was repaired and the arteriotomy closed with a saphenous vein patch graft. The incision was closed over a drain.

Postoperative recovery was uneventful and the patient is doing well, without any neurodeficit or other complication.

Discussion

‘Penetrating foreign body causing rupture of the common carotid artery’ was reported in 1931 by V.E.Negus.This patient had violent cough while eating a cake containing almond. Subsequently he developed fever and a tender swelling over the neck. Patient died after 20 days and the post mortem report revealed an injury to the common carotid artery through the lateral wall of pyriform fossa [1].

Few cases of migrating foreign body into the common carotid artery and internal jugular vein from the orodigestive tract had been reported in literature [2–4]. In such cases high degree of suspicion and imaging of the neck were key points in the diagnosis and surgical removal.

Pseudoaneurysms of the internal carotid artery due to trauma have been reported and have a high mortality rate. They generally present with epistaxis, ear bleed or neurodeficits.

Pseudoaneurysms of the external carotid artery are very rare [5, 6] and commonly involve the distal portions of its branches. However, in our case it involved the common carotid artery.

Now a days with increased use of interventional radiological & cardiological procedures, presence of various materials like catheter tip guidewire tip, ruptured balloons, embolisation coil [7] etc, are reported in vascular system. However penetrating foreign body in arterial tree, particularly in the common carotid artery is exceedingly rare [8]. After extensive literature search only one such case had been found to be reported from India in the last ten years, and in that case injury and the foreign body were detected immediately and the repair was done at the same time [8].

In our patient the injury had occurred two months back and there was minor local bleeding at that time , which had been repaired. Perhaps the foreign body was lodged initially outside, close to the carotid sheath and subsequently due to muscle movement of the neck, eroded through the internal jugular vein into the common carotid artery, producing AV fistula and pseudoaneurysm. Because of the metallic nature of the foreign body, MR angiography was not possible. Doppler ultrasound was done but could not predict the intraluminal position of the foreign body.

Exploration of the carotid sheath, palpation of some degree of induration in the common carotid artery and high degree of suspicion of intraluminal position of the foreign body were important steps to the successful operation in this case.

This case is rare both, in terms of presentation and in the position of the pseudoaneurysm (with the foreign body lodged in it) involving the common carotid artery.