Translate this page into:
A Hidden Culprit: Life-Threatening Upper Gastrointestinal Bleeding Due to a Subclavian Artery Pseudoaneurysm from an Impacted Fishbone
*Corresponding author: T. Rajeev, Department of Cardiothoracic and Vascular Surgery, Ambuja Neotia Getwel Multispecialty Hospital, Darjeeling, West Bengal, India. rajeev.t@neotiahealthcare.com
-
Received: ,
Accepted: ,
How to cite this article: Malakar J, Trehan R, Rajeev T. A Hidden Culprit: Life-Threatening Upper Gastrointestinal Bleeding Due to a Subclavian Artery Pseudoaneurysm from an Impacted Fishbone. J Card Crit Care TSS. 2026;10:215-8. doi: 10.25259/JCCC_23_2025
Abstract
Upper gastrointestinal (GI) bleeding is a common emergency with multiple etiologies, but vascular causes, particularly from arterial pseudoaneurysms, are rare. We present the case of a 67-year-old male with coronary artery disease, diabetes, and hypertension, who presented with hematemesis. Initial endoscopy revealed an actively bleeding mid-esophageal ulcer, which was managed with adrenaline injection, hemoclips, and hemospray. Despite stabilization, the patient experienced recurrent bleeding and developed accelerated hypertension, necessitating mechanical ventilation. A contrast-enhanced computed tomography angiogram revealed a left subclavian artery pseudoaneurysm eroding into the esophagus, with a suspected foreign body. Coronary angiography showed double-vessel disease, requiring percutaneous coronary intervention and stenting before surgical repair. Through left posterolateral thoracotomy, the pseudoaneurysm was exposed, revealing an impacted fishbone within the arterial wall. The foreign body was removed, and the artery was reconstructed with a 6-mm graft for an aorto-subclavian bypass. The patient had an uneventful recovery with no further bleeding. This case emphasizes the importance of considering vascular causes in refractory upper GI bleeding and highlights the role of early imaging and surgical intervention in managing rare but life-threatening conditions.
Keywords
Aorto-subclavian bypass
Esophageal fistula
Fishbone ingestion
Subclavian artery pseudoaneurysm
Upper gastrointestinal bleeding
INTRODUCTION
Upper gastrointestinal (GI) bleeding is a frequent medical emergency with potentially life- threatening consequences. Common causes include peptic ulcer disease, variceal hemorrhage, and malignancies. However, vascular anomalies as an etiology of upper GI bleeding are exceedingly rare and often present diagnostic and therapeutic challenges. Among these, arterial pseudoaneurysms eroding into the esophagus are an exceptionally uncommon but serious cause of refractory bleeding, often requiring multimodal intervention.
Foreign body ingestion is a well-recognized but often overlooked cause of GI injuries, with most cases involving small, sharp objects such as fishbones. These can migrate through the esophageal wall, leading to life-threatening vascular complications such as fistula formation or pseudoaneurysm development. The involvement of the subclavian artery in such a scenario is rare, making this case particularly unique.
We report a case of a 67-year-old male who presented with massive hematemesis, later found to have a left subclavian artery pseudoaneurysm secondary to an impacted fishbone. This case underscores the importance of maintaining a high index of suspicion for vascular causes in unexplained upper GI bleeding, especially in cases with recurrent or refractory bleeding despite endoscopic interventions. It also highlights the critical role of imaging, timely surgical intervention, and a multidisciplinary approach in achieving a favorable outcome.
CASE REPORT
Patient presentation
A 67-year-old male with a history of coronary artery disease, type 2 diabetes mellitus, and hypertension presented with hematemesis for 2 days. There was no history of melena, fever, shortness of breath, or seizures. On admission, his vital signs were stable, except for a blood pressure of 140/80 mmHg and a random blood glucose level of 261 mg/ dL. Laboratory investigations revealed a hemoglobin level of 8 g/dL. Upper GI endoscopy was performed, which showed active spurting hemorrhage from the mid-esophagus at 25 cm with a clot and unhealthy mucosa. Initial hemostasis was achieved with adrenaline injection, hemoclips, and hemospray. However, the patient developed accelerated hypertension post-procedure and required intubation and mechanical ventilation.
Investigations
Due to recurrent bleeding and hemodynamic instability, a contrast-enhanced computed tomography (CT) angiogram was performed to evaluate for a vascular cause. Imaging revealed a left subclavian artery pseudoaneurysm measuring approximately 9 mm from its origin, with a suspicious foreign body embedded within the vessel [Figure 1]. In addition, a bovine arch anomaly was noted. Coronary angiography demonstrated double-vessel coronary artery disease, necessitating percutaneous coronary intervention (PCI) and stenting of the left anterior descending (LAD) and right coronary artery before definitive surgical management of the pseudoaneurysm in view of mitigating the risk of perioperative myocardial infarction.
Surgical management
Decision for operative management entailed a thorough pre-operative assessment. A coronary angiogram revealed the patient to be affiicted with coronary artery disease as well, involving the LAD and the circumflex arteries. A percutaneous transluminal coronary angioplasty was done immediately, and the patient was administered anticoagulants in the form of dual antiplatelets. Now, the risks involved with surgery have exponentially increased, as stopping the antiplatelet drugs could lead to stent thrombosis, eventually leading to blockage and a risk for myocardial infarction. Nonetheless, the decision for surgery was taken under a moderate to high risk for bleeding and other complications.
A left posterolateral thoracotomy was performed through the fourth intercostal space. The thoracic cavity was accessed, and the subclavian artery was carefully dissected. Care was taken not to damage the pseudoaneurysm, as it could lead to catastrophic bleeding without any proximal control. The left subclavian was thereafter successfully looped. After taking initial control over the vessel, the subclavian artery was opened longitudinally, where a pseudoaneurysm was identified at the posteromedial aspects of the left subclavian artery. Upon opening the pseudoaneurysm, a fishbone was found embedded within the arterial wall. The foreign body was carefully removed, and the artery was reconstructed using a 6-mm synthetic graft to establish an aorto-subclavian bypass from the aorta to the distal subclavian artery. Hemostasis was meticulously achieved, and the thorax was closed in layers [Figure 2].
Intraoperative monitoring and anesthesia
The procedure was conducted under general anesthesia with endotracheal intubation. Invasive hemodynamic monitoring was employed, including arterial lines for continuous blood pressure monitoring and central venous access for fluid management. Standard monitoring included electrocardiogram, pulse oximetry, capnography, and temperature. The patient was maintained under controlled ventilation throughout the surgery.
Airway management
The patient was intubated electively in view of prior accelerated hypertension and respiratory distress after initial upper gastrointestinal endoscopy. A double-lumen endotracheal tube was used, and ventilation was optimized to maintain normocapnia and oxygenation. Lung isolation was not required as the field was approached through a standard thoracotomy, and no spillage from the esophagus was encountered.
Blood loss and transfusion
Intraoperative estimated blood loss was approximately 600 mL. The patient received 2 units of packed red blood cells intraoperatively and 1 unit postoperatively to maintain hemoglobin above 9 g/dL. Hemostasis was achieved meticulously before closure.
Anticoagulation
Heparin (unfractionated) was administered systemically during the vascular reconstruction phase to maintain an activated clotting time of ~250 s. Post-operative anticoagulation was deferred initially in view of recent upper GI bleeding and was cautiously resumed as soon as bleeding stopped with low- dose aspirin under hematological monitoring. Furthermore, given the history of pre-operative PCI, anticoagulation was started as soon as bleeding from the drain was seen to be on a decreasing trend, a few hours after surgery.
Antibiotic prophylaxis
Broad-spectrum antibiotics (e.g., cefoperazone-sulbactam and metronidazole) were administered perioperatively to cover both Gram-negative and anaerobic flora, considering the esophageal proximity and potential contamination. Antibiotic coverage was continued for 5 days postoperatively, tailored based on cultures (if any) and patient recovery.
Postoperative care
The patient was electively ventilated overnight and extubated the next day after ensuring respiratory adequacy and hemodynamic stability. In the Intensive Care Unit (ICU), close observation, including serial hemoglobin, lactate, electrolytes, and chest radiographs, was performed.
Nutritional support and Ryle’s tube (RT) feeds
Nasogastric tube placement was deferred initially to prevent disruption of the healing esophageal mucosa. The patient was maintained nil-per-oral for 48 h, receiving intravenous fluids and electrolyte correction. Enteral nutrition via RT feeds was initiated on postoperative day 3 after ensuring no further hematemesis and stable clinical parameters. Oral intake was gradually resumed by day 5 with a soft, non- irritant diet.
Postoperative course
The patient was extubated the following day and monitored closely in the ICU. His hemoglobin levels stabilized, and no further episodes of bleeding were observed. Serial imaging confirmed the integrity of the vascular repair. The patient had an uneventful recovery and was discharged in stable condition. Follow-up evaluations demonstrated good graft patency, and the patient remained asymptomatic.
This case highlights the rare but serious complication of vascular injury due to foreign body ingestion and underscores the importance of early recognition and multidisciplinary management in such scenarios.
DISCUSSION
Arterial pseudoaneurysms as a cause of upper GI bleeding are exceedingly rare but potentially fatal. Varices, in the lower esophagus, are the most common cause of upper GI bleed. The development of a pseudoaneurysm secondary to an impacted fishbone is an even more unusual occurrence. The esophagus is in proximity to several major vascular structures, including the aortic arch and its branches. Foreign body migration through the esophageal wall can lead to vascular injury, resulting in pseudoaneurysm formation or, in severe cases, fistulization and catastrophic hemorrhage.
Several reports have documented fishbone-induced pseudoaneurysms involving the aorta and its branches, but subclavian artery involvement is rarely described.[1,2] The mechanism likely involves gradual erosion of the vessel wall due to chronic inflammation, leading to weakening and eventual aneurysm formation. The presence of a bovine arch anomaly in this patient may have contributed to altered hemodynamic stress, potentially exacerbating vessel wall fragility.
Early imaging, including CT angiography, is essential in suspected vascular injuries associated with foreign body ingestion. Endoscopic evaluation alone may be insufficient in identifying such lesions, particularly in cases of intermittent bleeding. In this case, persistent hemorrhage despite endoscopic intervention necessitated further vascular imaging, leading to the identification of the pseudoaneurysm.
Management strategies for pseudoaneurysms depend on location, size, and hemodynamic stability. Endovascular techniques, including coil embolization and stent– graft placement, are increasingly used for arterial pseudoaneurysms.[3,4] However, in cases where foreign bodies are implicated or when endovascular access is challenging, open surgical repair remains the gold standard.[4]
CONCLUSION
This case highlights the importance of considering vascular causes in unexplained or refractory upper GI bleeding and reinforces the role of early imaging and surgical intervention in managing rare but life-threatening conditions. The successful outcome in this case underscores the need for a multidisciplinary approach, integrating gastroenterologists, radiologists, and vascular surgeons, to ensure timely diagnosis and intervention. Vigilance for foreign body ingestion, particularly in at-risk populations, should be emphasized to prevent such potentially fatal complications.
Authors’ contributions:
JM: Concepts, design, definition of intellectual content, literature search, clinical studies, experimental studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing and review; RT: Concepts, design, literature search, data acquisition, data analysis, manuscript preparation; TR: Manuscript editing and review, data analysis, statistical analysis.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- CT in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract. AJR Am J Roentgenol. 2006;187:710-4.
- [CrossRef] [PubMed] [Google Scholar]
- Fish bone foreign body: the role of imaging. Int Arch Otorhinolaryngol. 2019;23:110-5.
- [CrossRef] [PubMed] [Google Scholar]
- A prospective study of epidemiological risk factors for ingestion of fish bones in Singapore. Singapore Med J. 2015;56:329.
- [CrossRef] [PubMed] [Google Scholar]
- Fish bone induced bronchial artery pseudoaneurysm in a patient with underlying bronchiectasis-a case report. Egypt J Radiol Nucl Med. 2020;51:128.
- [CrossRef] [Google Scholar]