Discussion

Extracranial carotid artery pseudoaneurysms in the paediatric population are exceedingly rare and most commonly arise secondary to trauma, infection, or iatrogenic injury.^{Reference Pourhassan, Grotemeyer and Fokou1,Reference Fankhauser, Stone and Fowl2} Vascular complications related to foreign body ingestion are particularly uncommon, with only a limited number of paediatric cases reported in the literature.^{Reference Jean Roger, Marcus, Emmanuel, Boniface and Alain Georges3} In such cases, the initial vascular insult may remain clinically silent, leading to delayed pseudoaneurysm formation and presentation as a slowly enlarging, painless cervical mass months after the inciting event.^{Reference Jean Roger, Marcus, Emmanuel, Boniface and Alain Georges3}

CT angiography remains the imaging modality of choice for diagnosis and preoperative planning, providing detailed information regarding aneurysm morphology, size, and its relationship to adjacent neurovascular structures.^{Reference Moreno Real and de Araújo Martins-Romêo5} Early recognition is critical, as untreated carotid pseudoaneurysms carry a substantial risk of rupture, thromboembolic events, and neurological complications, particularly in children.^{Reference Imtinene, Miri and Melek6}

The primary objective of surgical management is complete exclusion of the pseudoaneurysm while maintaining adequate cerebral perfusion. Available surgical options include aneurysm resection with interposition grafting, primary end-to-end anastomosis, and, less commonly, endovascular approaches.^{Reference Pourhassan, Grotemeyer and Fokou1,Reference Fankhauser, Stone and Fowl2,Reference Davis, Eliason, Ganesh, Blatt, Stanley and Coleman7} In paediatric patients, avoidance of prosthetic graft material is generally preferred because of concerns regarding infection risk, long-term durability, and the inability of synthetic conduits to accommodate somatic growth.^{Reference Pourhassan, Grotemeyer and Fokou1,Reference Davis, Eliason, Ganesh, Blatt, Stanley and Coleman7} When sufficient arterial mobilisation can be achieved, primary end-to-end anastomosis offers a physiologic reconstruction with favourable long-term patency.^{Reference Pourhassan, Grotemeyer and Fokou1}

The use of temporary intraluminal shunts or bypass grafts during extracranial carotid artery repair in children remains controversial. While shunting may theoretically reduce the risk of cerebral ischaemia during prolonged carotid clamping, it is also associated with potential complications, including intimal injury, embolisation, and increased technical complexity in small-calibre vessels.^{Reference Fankhauser, Stone and Fowl2,Reference Davis, Eliason, Ganesh, Blatt, Stanley and Coleman7} In the present case, a temporary shunt was not used because secure proximal and distal vascular control was achieved, collateral cerebral perfusion was deemed adequate, and the total clamp time was limited to 12 minutes. Avoiding shunt placement allowed a simplified and physiologic repair while minimising vessel manipulation and foreign material.

Similarly, no active hypothermic cerebral protection was employed. Given the short clamp duration, normothermic conditions with continuous neurovascular monitoring were considered sufficient, consistent with previously reported paediatric carotid reconstructions performed under brief ischaemic intervals.^{Reference Pourhassan, Grotemeyer and Fokou1,Reference Davis, Eliason, Ganesh, Blatt, Stanley and Coleman7}

This case underscores several important considerations. First, vascular injury should be included in the differential diagnosis of paediatric patients presenting with delayed cervical masses following foreign body ingestion.^{Reference Jean Roger, Marcus, Emmanuel, Boniface and Alain Georges3} Second, when anatomic conditions permit, complete excision of the pseudoaneurysm followed by primary end-to-end anastomosis without shunt or graft may represent a safe and effective surgical strategy.^{Reference Pourhassan, Grotemeyer and Fokou1,Reference Davis, Eliason, Ganesh, Blatt, Stanley and Coleman7} Finally, individualised intraoperative decision-making—rather than routine use of shunts or grafts—appears particularly relevant in paediatric carotid surgery, where vessel size and long-term outcomes must be carefully balanced.^{Reference Fankhauser, Stone and Fowl2}

Although long-term follow-up data in paediatric carotid pseudoaneurysms remain limited, the absence of neurological complications or anastomotic stenosis during two years of follow-up in our patient supports the durability of primary repair in selected cases.^{Reference Pourhassan, Grotemeyer and Fokou1} Further accumulation of similar cases will be necessary to better define optimal management strategies and long-term outcomes in this rare clinical entity.