2025 Volume 12 Pages 27-31
An aberrant course of the carotid artery can cause dysphagia by displacing the pharynx, but no definitive treatment strategy has been established for this condition. We report a case in which swallowing discomfort was improved by surgical transposition of a carotid artery following a highly medial course. A 79-year-old man presented with worsening swallowing discomfort over the preceding year. Computed tomography angiography of the head and neck showed tortuous right common and internal carotid arteries running through the retropharyngeal space. Videoendoscopic and videofluorographic examinations revealed intact swallowing function and the carotid artery compressing the right pharyngeal wall. Since the cause of swallowing discomfort was suspected to be the tortuous courses of the right common and internal carotid arteries, we performed surgery to change the course of the carotid artery. The surgical procedure moved the common and internal carotid arteries from the retropharyngeal space. The carotid artery was retracted anterolaterally with the carotid sheath, which was fixed to the sternocleidomastoid muscle to maintain the corrected course. Symptoms showed immediate improvement postoperatively. Our strategy appears effective as a method of treating swallowing discomfort due to tortuosity of the carotid arteries.
The internal carotid artery (ICA) typically shows a straight course from the carotid bifurcation to the intracranial space. However, variations of the ICA, such as curving, kinking, and coiling, are reportedly found in 10%-40% of the general population.1) An aberrant course of the ICA has been reported to cause dysphagia due to compression and narrowing of the pharynx.2) Surgical treatment has been reported for this condition in relatively few cases, so the methods and indications for treatment have yet to be established. We report a case in which surgical transposition of an extremely medialized carotid artery causing swallowing discomfort resulted in significant symptomatic improvement.
A 79-year-old man experienced worsening swallowing discomfort for over a year. He had first visited an otolaryngologist, but his swallowing function was judged as normal on videoendoscopic evaluation (VE). Due to persistent symptoms, his primary care physician performed plain computed tomography (CT) of the neck, revealing a markedly aberrant course for the carotid artery. The patient was then referred to our hospital. CT angiography (CTA) of the head and neck showed the tortuous right common carotid artery (CCA) and ICA running medial to the hyoid bone and compressing the pharynx (Fig. 1A, B). Additional VE revealed compression of the right pharyngeal wall by a pulsatile mass (Fig. 1C). Videofluorographic examination (VF) performed at the same time as head and neck catheter angiography showed barium water mainly passing through the left side of the pharynx without stagnation or residue (Fig. 1D), indicating that the swallowing function itself was preserved. However, the right side of the pharynx was compressed and narrowed by the carotid artery.
A, B) Axial (A) and 3-dimensional (B) computed tomography angiography of the neck. The common carotid artery (yellow arrow) and internal carotid artery (yellow arrowhead) run medial to the hyoid bone (double arrowhead), narrowing the pharynx. C) Preoperative videoendoscopic evaluation. A pulsatile mass (yellow arrow) is observed in the right pharyngeal wall. D) Results of videofluorographic examination conducted at the same time as catheter angiography. The course of the right common carotid artery (yellow arrow) is shown in (1). Barium water flowed quickly without delay or residue, mainly passing to the left of the pharynx ( (2) - (4) yellow arrowhead).
Based on these findings, the cause of swallowing discomfort was suspected to be the right CCA and ICA compressing and narrowing the pharynx. Although we initially proposed conservative observation, the patient strongly requested surgical treatment because the symptom was significantly impairing his quality of life. We decided to perform surgery to release pharyngeal compression by the aberrant carotid artery after obtaining informed consent from the patient.
The surgery was performed under general anesthesia. A skin incision was made along the anterior edge of the right sternocleidomastoid muscle (SCM). Before opening the carotid sheath, the carotid artery was observed to run underneath the hyoid bone (Fig. 2A). When the carotid sheath was incised and retracted laterally, the carotid artery was moved toward the outside of the hyoid bone (Fig. 2B). The ICA was exposed by further incision of the carotid sheath (Fig. 2C). The carotid artery, along with the carotid sheath, was moved anterolaterally to the internal jugular vein and sutured and fixed to the SCM so that the course of the artery would not return to the previous position in the retropharyngeal space (Fig. 2D, E).
Intraoperative view. A) The right common carotid artery (CCA) initially runs medial to the edge of the hyoid bone (dotted line). B) The CCA is moved from medial to the lateral side of the hyoid bone after opening the carotid sheath. C) The internal carotid artery (ICA) is exposed. D, E) The carotid artery is moved to lateral to the IJV, and the carotid sheath is sutured to the SCM to ensure the altered course of the carotid artery is maintained.
CCA: common carotid artery; ICA: internal carotid artery; IJV: internal jugular vein; SCM: sternocleidomastoid muscle
Swallowing discomfort disappeared immediately after surgery. At the 6-month follow-up, the patient showed no recurrence of symptoms and CTA of the head and neck showed that the carotid artery remained in the surgically altered course, lateral to the hyoid bone (Fig. 3A, B). Postoperative VE showed that the pulsatile mass in the right pharyngeal wall had disappeared (Fig. 3C, D).
A, B) Comparison of 3-dimensional computed tomography angiography between before (A) and 6 months after (B) surgery (right common carotid artery, yellow arrows). The right common carotid artery remains lateral to the hyoid bone after surgery. C, D) Videoendoscopic evaluation (VE) before (C) and after (D) the surgery. The pulsatile mass evident on preoperative VE is no longer seen on postoperative VE.
VE: videoendoscopic evaluation
An aberrant course of the ICA is observed in 10-40% of the general population.1) According to Weibel and Fields, these ICA anomalies can be classified into three categories: tortuosity, kinking, and coiling.3) Such aberrations can lead to widening of the parapharyngeal space and subsequent migration of the ICA into the retropharyngeal space and compression of the posterior pharyngeal wall.4) Although up to 80% of individuals with parapharyngeal ICA remain asymptomatic, common symptoms include difficulty with swallowing and speaking, dysphagia, a foreign body sensation, and intraoral pulsations.5)
The pathogenesis of a tortuous carotid artery is not fully understood and may involve various factors. One hypothesis suggests that ICA aberrations may originate during embryogenesis. The ICA develops from the junction of the third aortic arch and the cranial part of the aorta. A loop of ICA is formed at the junction of these two vessels by the fifth week of fetal development. Normally, the artery uncoils when the heart and great vessels descend into the mediastinum, straightening the course of the ICA. Abnormalities in this process might then result in the persistence of the loop of the ICA, leading to an aberrant ICA.1) Another viewpoint considers age-related factors, such as decreased vascular elasticity and arteriosclerosis.1,6) Despite these viewpoints, no definitive consensus has been reached regarding the origin of these variations.7)
Several previous reports have described the treatment of dysphagia caused by a tortuous ICA.7-10) In most of those studies, ICA resection was performed to straighten the vessel, as summarized in Table 1. One exception involved CCA transposition without arteriotomy when the CCA was compressing the esophagus.8)
Literature review of surgical interventions for tortuous carotid arteries associated with dysphagia
| Authors, year | Symptoms | Etiology | Surgical procedure |
|---|---|---|---|
| *A 6-mm ePTFE prosthesis was used for intraoperative dissection of the distal stump of the ICA after ICA resection. | |||
| Coppola et al., 1964 | dysphagia | CCA (elongation) | surgical repositioning (no resection) |
| Stilo et al., 2017 | dysphagia | ICA (kinking) | ICA resection, *end-to-end anastomosis with 6-mm ePTFE prosthesis |
| Antunes et al., 2018 | dysphagia | ICA (tortuosity, kinking) | ICA resection, end-to-end anastomosis |
| Landis et al., 2021 | dysphagia, burning mouth syndrome | ICA (coiling) | ICA resection, end-to-end anastomosis |
A tortuous ICA may also be associated with ischemic stroke.11) A large number of surgical interventions have been reported for stroke-related aberrant carotid arteries, as distinct from cases presenting with dysphagia. The most common surgical procedures in such cases were ICA transection and ICA-CCA bypass.12-16) Although ICA resection or bypass to straighten the course can be effective according to previous reports, potential risks include narrowing of the lumen, stenosis due to suture, and perioperative vessel occlusion resulting from mural thrombosis.17,18) Benes and Mohapl19) described a simple technique of fixing the ICA to surrounding muscles to relieve kinking, similar to the maneuver we applied. Outcomes were comparable to those of ICA transection and ICA-CCA bypass technique: rates of perioperative death and perioperative stroke were both 0%, and 2.5% of patients experienced transient ischemic attacks during follow-up (range, 1-15 years). This confirms that simple transposition procedures are as safe as those requiring arteriotomy. Benes and Mohapl19) also suggested that ICA transposition could be the first-choice surgery to release tortuosity of the ICA, but if a proper position of the ICA cannot be achieved, resection of the ICA should be considered. Although their cases were limited to tortuous ICAs related to stroke, the operative strategy and procedure may be useful for treating patients with tortuous carotid arteries compressing the pharynx and presenting with dysphagia.
In this case, we performed transposition of a tortuous carotid artery causing swallowing discomfort. No arteriotomy or bypass was required and a good outcome was achieved. Our approach offers the advantage of avoiding arteriotomy, reducing the risk of perioperative thromboembolic complications. This may represent an effective method for an extremely medialized carotid artery causing swallowing discomfort.
The final version of the manuscript was approved for publication by all contributors to this case report.
The patient consented to the publication of his images and clinical description.
All authors have no conflict of interest.
