Simultaneous retropharyngeal course of three carotid arteries coexisting with internal carotid coiling: a unique...

Variations (topographical) in the course of the carotid arterial system are well-documented. Still, their clinical significance lies in their potential to alter cervical anatomy and increase the risk of iatrogenic injury. Retropharyngeal displacement most often involves the internal carotid artery (ICA), while involvement of the external carotid artery (ECA) or common carotid artery (CCA) is rarely reported. Simultaneous displacement of multiple carotid arteries (CAs) is extremely rare.

We describe a 40-year-old female patient in whom computed tomography angiography (CTA) revealed an unusual constellation of vascular variants.

Both ICAs and the ipsilateral ECA traveled through the retropharyngeal space. Bilateral carotid bifurcations were twisted. The right ICA showed a coiled shape at the level of the styloid process, and both CCAs were found in unusually close proximity to the superior cornu of the thyroid cartilage. No signs of atherosclerosis were seen, indicating a developmental rather than acquired variant.

This case expands the range of known cervical vascular topographies by showing, for the first time, a tri-arterial retropharyngeal configuration with concurrent ICA coiling. While isolated or bilateral retropharyngeal displacements of the ICA, CCA, or superior thyroid artery have been documented, the presence of three major arteries in this compartment simultaneously seems unprecedented. Recognizing such extreme variants is essential for preventing severe hemorrhage and for guiding surgical and anesthetic planning in the anatomically restricted retropharyngeal region.