A Hidden Culprit: Life-Threatening Upper Gastrointestinal Bleeding Due to a Subclavian Artery Pseudoaneurysm from an Impacted Fishbone

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.