A Strange Esophageal Foreign Body: Coil Extrusion After Embolization of a Common Carotid Artery

There have been described cases of coil migration into the oropharyngeal,1 sinus,2 middle ear,3 and endonasal4, 5 regions following management of pseudoaneurysms of the internal carotid artery. In this article, we describe the first case of esophagus coil migration after embolization of common and external carotid pseudoaneurysms responsible for recurrent bleeding following postradiation chondronecrosis. This study was performed in accordance with the principles of good clinical practice and the need for Ethics Committee approval was waived. In July 2023, a 62-year-old patient with a medical history of embolization of the right common carotid artery presented to the ears, nose, and throat (ENT) emergency consultation for presenting dysphagia, odynophagia, dysphonia, and altered general condition. The patient complained of mouth expectoration of an iron wire, that occurred few days before. Nothing abnormal was detected at the nasofibroscopy. The patient had no bleeding, and no pain. The patient had a history of laryngeal squamous cell carcinoma, treated initially in 2010 with exclusive radiotherapy, followed by cervical recurrence in 2020 treated with radiochemotherapy as a complement to surgery. He came to the emergency department in 2022 with several episodes of blood expectoration. A computed tomography (CT) scan showed chondronecrosis of the right wing of the thyroid cartilage and 2 pseudoaneurysms of the right superior thyroid artery (4 mm) and the right common carotid artery (5 mm). Therefore, he had undergone right common carotid artery embolization (after failure of right superior thyroid artery occlusion in reason of spasm) and tracheotomy. He received 3 plugs and 10 coils. A total of 10 coils were deployed, of varying lengths (between 200 and 400 mm) and different spherical diameters (between 5 and 10 mm). All the coils were from the “Axial detachable coils” range produced by Medtronics. The 3 vascular plugs used were Medtronics Micro Vascular Plugs. One year later, in absence of recurrent bleeding, he had been weaned of his tracheotomy canula. A CT scan was performed in emergency, and found a coil going from the right carotid bulb spreading through the esophagus over 9.7 cm (Figures 1 and 2A). This reference to a coil length of 9.7 cm corresponds only to the length of the free coil in the soft tissue. After a discussion between the ENT surgeons, the gastroenterologists and the radiologists, a therapeutic abstention was decided. The balance between the benefices and the risks of any radiological or surgical intervention (diagnostic or therapeutic esophagoscopy) was too risky. Given the patient's condition with a postradiation neck, a difficult exposure, the risk of esophageal perforation, and the risk of bleeding, we decided simple clinicoradiological follow-up and therapeutic abstention. Moreover, the arteries embolized were still occluded because the coils were still in place. The patient stayed 2 days in observation in the ENT department. In the absence of coil expectoration, and no bleeding, the patient could go back home. Six weeks later, a new CT scan was performed. The fistulized coil was at the same place, but less extended (4.1 cm in the esophagus) due to another expectoration at home (Figure 2B). Six months later, the patient came in consultation with a control CT scan, where the extruded coil is only 3 cm inside the esophagus (Figure 2C). The patient was asymptomatic. The patient should be re-examined in 6 months with a new CT scan. In this work, we describe a case of spontaneous extrusion of common carotid artery coil inserted a year previously by our neuroradiology colleagues for the treatment of 2 pseudoaneurysms responsible for recurrent bleeding following postradiation chondronecrosis without tumor recurrence. The coils were inserted in an environment reworked by the disease and the treatment, which facilitated this migration. After collegial discussion, we decided to leave the remaining coils in place in the esophagus to avoid a recurrence of bleeding. Depending on where the coils have migrated, symptoms may vary1-4 and may lead to major bleeding requiring emergency treatment.4 In the case of embolization of a carotid artery pseudoaneurysm in an irradiated region, it is important to follow the patients closely from a radioclinical approach, because this is a vulnerable area which could change over time and could increase the risk of coil migration. Shakyl Apithy, drafting the article, final approval of the version to be published, and agreement to be accountable for all aspects of the work; Stanley Tetard, drafting the article, final approval of the version to be published; Marc Lenfant, analysis and interpretation of radiography for the work; Caroline Guigou, drafting the article, drafting the legends of panels, final approval, and accountability for the work. The authors declare that there is no conflict of interest. None.