Esophageal perforation resulting from foreign body ingestion is a rare occurrence. Most of the complications associated with this event, such as retroesophageal abscess, mediastinitis, pericarditis, pneumothorax, and pneumomediastinum, are widely recognized. However, little attention has been directed to the possibility of vascular injury caused by the perforating object. Isolated case reports have described significant morbidity and mortality subsequent to major vascular trauma resulting from an esophageal foreign body, usually emphasizing the presence of a "signal" hemorrhage from the gastrointestinal tract as a key to diagnosis. This report describes a case of esophageal perforation caused by an ingested fishbone that resulted in significant aerodigestive hemorrhage, possibly as the result of an unusual isolated vascular injury. The literature on vascular trauma following foreign body perforation of the esophagus is reviewed, and suggestions for the diagnosis and treatment of these dreaded complications are made.