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A woman of 82 was seen in outpatients after eight weeks of mild postcibal epigastric discomfort. She also gave a long history of dysphagia. 18 years previously, dilatation of an oesophageal stricture had been unsuccessful and the dysphagia had continued—only to solids, with occasional episodes of food bolus obstruction and difficulty in swallowing certain tablets. There had been no weight loss or change in appetite.
Her medical history included polymyalgia rheumatica, for which she was on steroids, and hypertrophic cardiomyopathy. She had smoked till the age of 40. On examination there was no pulsatile mass in the neck and the carotid pulsations on both sides were normal. A barium swallow showed a tight stricture of the lower cervical oesophagus with dilatation of the pharynx and the upper cervical oesophagus proximal to the stricture. The stomach and the duodenum were normal. The stricture had a smooth margin consistent with an extrinsic compression (Figure 1). MRI of the neck showed a tortuous right common carotid artery indenting the oesophagus (Figures (Figures22 and and3).3). Upper gastrointestinal endoscopy was not performed because of the patient's poor cardiac status.
Dysphagia from carotid artery kinks and coils seems very rare. In reported cases the internal carotid artery has usually been responsible. We have found only one case due to common carotid artery tortuosity—in which the redundant part of the artery was surgically resected and the dysphagic symptoms resolved completely.4 Elongation and kinking of the carotid artery are usually due to atherosclerosis or fibromuscular dysplasia,5 but the unusual location of the proximal common carotid artery coil in this patient is most likely congenital rather than atherosclerotic.
In a fitter patient the treatment of choice would have been a carotid shortening procedure. Dilatation by balloon or stent might provide palliation at the risk of cerebrovascular catastrophe and is contraindicated unless the vessel is known to be occluded.