Percutaneous Removal of Intravascular Pellet Following Penetrating Cardiac Trauma

Systematic review of civilian intravascular ballistic embolism reports during the last 30 years

BACKGROUND

Intravascular ballistic embolization is a rare complication of missile injury. Because of its rarity, much remains to be known about its presentation, pathophysiology, complications, and management. In this study, we analyze case reports of ballistic embolization in the last 30 years and available cases from our institution to determine the likely patient, the nature of the embolization, the possible complications, and a general management strategy.

METHODS

A PubMed search was performed in search of missile embolization cases from 1988 to 2018 in the English language, including only cases of intravascular emboli. Cases resulting from combat and explosive devices were excluded. In addition, five cases from our institution were included in the analysis.

RESULTS

A total of 261 cases were analyzed. The most common presentation was that of a young man (reflecting the demographics of those sustaining gunshot wound injuries) with injury to the anterior torso from a single gunshot wound. Venous entry was most common, most often through large-caliber vessels. There was roughly equal involvement of the right and left circulation. Left circulation emboli were frequently symptomatic, with ischemia being the most frequent sequela. In contrast, a right circulation embolus was rarely associated with significant complications.

CONCLUSIONS

Despite its rarity, ballistic embolization should be considered in gunshot injury with known large-vessel injury when an exit wound is not identified. In particular, signs of ischemia distant from the injury site warrant timely investigation to maximize tissue salvageability. We present a management strategy model for consideration.

Penetration of the Heart by an Airgun Pellet: A Case Without Significant Effusion or Valvular Injury

Cardiac gunshot injuries are rare in the United Kingdom, but they are associated with significant morbidity and mortality. We present the case of a young male who was shot at close range with a low-caliber air rifle. The projectile entered the thorax through the right axilla, but it was identified at the cardiac apex on initial imaging. Subsequent investigations demonstrated the pellet at the apex of the left ventricle. The potential for embolization was considered, and the pellet was retrieved after surgical exploration. No significant valvular injury was sustained despite the pellet's trajectory, and the patient made an uncomplicated recovery.