B53-01 Successful Retrieval of a Rare Migrating Fish Bone Injury to the Left Subclavian Artery by a Well-planned Multidisciplinary Surgical Approach

Fishbones are the most common type of foreign bodies to become lodged in the oropharynx & esophagus, but rarely perforate the oesophagus & migrate to the mediastinum. Penetrating injuries to the blood vessels of the mediastinum can be life-threatening, from the risk of mediastinitis & vasculitis with bleeding complications. We present a rare case of a 51-year-old gentleman who presented with complaints of fever, 2 days post-accidental ingestion of a fish bone that had penetrated his esophagus & migrated into the superior mediastinum & penetrated again the left subclavian artery, which was successfully retrieved in toto, by a well-planned surgery. The patient was diabetic with HBA1C over 7 on admission with elevated inflammatory markers. He was started on broad spectrum antibiotics, & underwent an oesophagoscopy, & intraoperative angiography of mediastinal great vessles, without any significant findings, so he underwent Left uniportal video-assisted thoracoscopic surgery converted to high mini thoracotomy at the 3rd intercostal space, as the left subclavian artery looked purplish blue in thoracoscopy from severe vasculitis & indurated mediastinal fat. Meticulous dissection & on lifting the root of the subclavian artery, the fish bone, which was at an inaccessible location, got dislodged & dropped into the mediastinum medial to the artery, causing severe arterial bleeding. But patient was well prepared preoperatively with defibrillator pads, central line insertion, left femoral artery & venous sheaths for emergency cardiopulmonary bypass, right radial arterial line monitoring in case the left subclavian artery needs clamping, &an image intensifier operating theatre in case the patient needs endovascular stenting. But on manual pressure around the left subclavian artery, the bleeding stopped. Post operatively patient was discharged on day 14 with a repeat CT angiogram showing 2 mm left pseudoaneurysm which on further scanning is getting smaller, with resolution of mediastinitis picture in imaging & normalization of inflammatory markers. Our case highlights the importance of early & well-planned surgical intervention with multi-disciplinary team involvement in these rare cases of organic penetrating injuries, which otherwise can be fatal from mediastinitis & vasculitis leading to rupture or fistula formation. To the best of our knowledge, this is the first case report in recent times demonstrating a well-planned approach of removing a penetrating organic sharp injury to the the left subclavian artery with minimal sequelae & survival benefit.