Venous bullet embolism: a case report and review of the literature

Projectile Embolism From a Firearm Injury: A Case Report

Projectile embolism resulting from firearm injuries is a rare but highly lethal complication when not diagnosed early. This report presents a case of projectile embolism from a firearm injury with an unusual entry site, the cerebral venous circulation, which subsequently migrates to the pulmonary circulation with a fatal outcome. A 24-year-old male patient was admitted to a high-complexity hospital due to a gunshot wound. A plain skull computed tomography (CT) revealed a left laminar subdural hematoma and traumatic subarachnoid hemorrhage with multiple metallic fragments embedded in the skull, some penetrating the galeal sinus, with perilesional bleeding. Contrast-enhanced chest tomography showed non-thrombotic embolism of metallic fragments in the pulmonary artery for the apical segment of the left upper lobe and right intraventricular regions. Transthoracic echocardiography revealed a hyperechoic image of 3 mm in the subvalvular apparatus toward the interventricular septum. Subsequently, the patient experienced neurological deterioration with signs of cerebral edema and parieto-occipital epidural hematomas with metallic fragments and projectiles. Measures to counteract cerebral edema were initiated. Later, the patient developed mydriasis, the absence of brainstem reflexes, and experienced cardiac arrest. This report delineates a case of projectile embolism, highlighting a distinctive aspect characterized by an unusual entry point.

Management of Bullet Emboli to the Heart and Great Vessels

INTRODUCTION

Firearm-related injuries account for 20% of all injury-related deaths and are responsible for 105,000 injuries annually. The occurrence of bullet emboli to the heart is exceedingly rare. Given the rarity of emboli, controversy exists over management. The primary endpoint of this study is to establish a management algorithm for venous bullet emboli to the heart.

MATERIALS AND METHODS

A literature search was performed using PubMed and Google Scholar with the following search terms: cardiac bullet embolus, cardiac missile embolus, and bullet embolus. Any discoverable case report(s) or series after 1960 were included in the review. The following data points were collected: age, sex, presentation, imaging, foreign body entry site, foreign body destination site, management, and outcomes.

RESULTS

Fifty-four articles met our search criteria. A total of 62 patients with thoracic venous bullet emboli were identified with the following distributions: right atrium (9.7%), right ventricle (54.8%), pulmonary arterial tree (32.3%), and intra-thoracic inferior vena cava (3.2%). Only 11.3% of patients had symptoms directly related to the cardiac venous emboli; however, all patients with acute symptoms underwent immediate intervention. Of those patients with bullet emboli to the pulmonary arterial tree, 45% were observed; whereas, only 20% with emboli to the right heart were observed. Those without signs or symptoms usually underwent an intervention (72.7%). Endovascular retrieval was successful in 53% of attempts. Of the endovascular attempts that failed, 28.6% were observed and 71.4% underwent open retrieval. Those who were asymptomatic and observed had no reported adverse sequelae during the follow-up. No mortalities were discovered in this review.

CONCLUSION

Bullet emboli can prove to be a clinical challenge. Adjuncts such as X-ray, computed tomography, transthoracic, and/or transesophageal echocardiography help establish the emboli location. While observation in the asymptomatic patient is reasonable in some circumstances, most patients undergo removal. Removal of bullet cardiac emboli is safe with the availability of modern techniques.

Percutaneous retrieval of an embolized gunshot bullet from right ventricle: a case report and review of literature

Background

Gunshots embolizing to the heart is a rare occurrence. We report a case of percutaneous retrieval of a gunshot bullet from the right ventricle (RV) cavity of a 40-year-old lady. To the best of our knowledge, this is the first case to be reported with a right supraclavicular inlet of the bullet and successful percutaneous retrieval using a snare from the RV cavity.

Case summary

A 40-year-old female patient was referred to our cardiac centre from a general hospital with a gunshot injury 8 days prior. On arrival, she was haemodynamically stable, there was an inlet wound at the right supraclavicular area. Transthoracic echocardiography revealed the bullet in the RV cavity. Under conscious sedation, right femoral vein access succeeded to retrieve the shot from the RV to the groin. The bullet slipped out and resnared from the right internal iliac vein and came out safely from the right femoral vein through the 24-Fr sheath. The vein was closed using a figure of 8 suture. The patient discharged home after 2 days.

Discussion

Bullet emboli to the heart are rare, endovascular retrieval of a bullet from the right ventricular cavity is feasible and relatively safe; however, more research is required. Echocardiography during the procedure is strongly recommended to early detect any complications. Accurate use of available tools such as X-ray, echocardiography, computed tomography, and fluoroscopy is a must for precise diagnosis.

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.

Pulmonary artery embolism by a metal fragment after a booby trap explosion in a combat patient injured in the armed conflict in East Ukraine: a case report and review of the literature

Background

Pulmonary artery embolization due to projectile embolus is a rare complication in combat patients. Such embolization is rare for combat patients in the ongoing armed conflict, in East Ukraine since 2014.

Case presentation

We report a clinical case of a 34-year-old Caucasian combat patient who was injured after an explosion of a booby trap hand grenade. This soldier was diagnosed with severe abdominal and skeletal trauma: damage of the duodenum and transverse colon, internal bleeding due to inferior vena cava damage and fractures of both lower extremities. The patient was treated at a highly specialized surgical center within the “golden hour” time. Whole-body computed tomography scan was performed as a routine screening method for hemodynamically stable patients, at which we identified a projectile embolus due to the explosion of a booby trap hand grenade in the right midlobar pulmonary artery. Our patient had no clinical manifestation of pulmonary artery embolism. At follow-up, our patient was diagnosed with the following complications: multiple necrosis and perforations of the transverse colon leading to a fecal peritonitis; duodenum suture line leakage caused the formation of a duodenal fistula; postoperative wound infection. These complications required multiple secondary operations, and in accordance to the principles of damage-control tactics, the extraction of projectile-embolus was postponed. Open surgery retrieval of the metal fragment was successfully performed on the 80th day after injury. Our patient was discharged from the hospital on day 168th after injury.

Conclusions

Literature analysis shows a significant difference of clinical management for patient with projectile embolism in hybrid war settings as compared to previously described cases of combat and civil gunshot injuries. Damage control tactics and the concept of the “golden hour” are highly effective for those injured in a hybrid war.

A whole-body computed tomography scan is an effective screening method for asymptomatic patients with projectile-embolism of the great vessels.

The investigation of a greater cohort of combat patients with severe injuries and projectile-embolism should be performed in order to develop a better guideline for these patients and to save more lives.

A Case Series of Anterograde and Retrograde Vascular Projectile Embolization

Deaths related to firearms are common within the United States, with most cases having conspicuous projectile wounds found at autopsy. Individual gunshot wounds may be perforating or penetrating. In most cases with penetrating wounds, projectiles are relatively easily found via radiography and by following the pathway on internal examination. When a projectile is not detected in the expected region, intravascular embolization of the projectile should be suspected. Embolization may be arterial or venous, as well as anterograde or retrograde. Typically, such emboli involve small caliber bullets or shot pellets. The authors present three unusual cases of intravascular projectile embolization at autopsy, one involving shotgun slug fragment embolization, one where death was delayed, and one with retrograde embolization into the liver. Acad Forensic Pathol. 2018 8(2): 392-406.

Percutaneous Removal of Intravascular Pellet Following Penetrating Cardiac Trauma

There is controversy regarding the management of projectile embolization, a rare complication of penetrating trauma. We present the case of a 5-year-old, 20 kg male with retrograde venous projectile embolization following traumatic injury with a pellet gun. The projectile was successfully removed utilizing a novel, percutaneous approach.

Unusual venous bullet embolism - Case report

Bullet embolism is rare complication of penetrating gunshot trauma. We are presenting a case of a single gunshot with entrance wound located on external side of a left thigh. The upward directed trajectory extends to the left lateral side of the neck, but the bullet has been recovered from right external iliac vein. The bullet migration was explained due to one rare variation of the mouth of vena cava superior and inferior.

Pulmonary artery bullet embolism-Case report and review

INTRODUCTION

Bullet embolism, an uncommon but serious complication of penetrating vascular trauma, poses a unique clinical challenge for the trauma physician. Migration of bullets can lead to infection, thrombosis, ischemia, hemorrhage and death.

PRESENTATION OF CASE

We report a patient in whom a bullet embolized from the left femoral vein to the right pulmonary artery, a situation ultimately managed by observation alone.

DISCUSSION

Bullet embolism should be suspected when the number of penetrating entry wounds exceeds the number of exit wounds. Patients with radiographic studies showing a bullet outside the established trajectory require further evaluation. Most bullet emboli are arterial, and are generally symptomatic presenting with early signs of ischemia. Venous emboli are less common, and they are generally asymptomatic. Most venous bullet emboli travel in the direction of the blood flow and may lodge in the pulmonary arterial tree causing serious complications. Management of bullet emboli in the pulmonary arterial tree remains controversial and specific guidelines have not been clearly established. However, the available data in the literature suggest that pulmonary artery embolism can be observed in the asymptomatic patient.

CONCLUSION

Symptomatic pulmonary bullet emboli should be managed with endovascular retrieval when available or operative therapy. Asymptomatic intravascular bullet emboli may be managed conservatively as seen in our patient.

The evolving management of venous bullet emboli: a case series and literature review

Bullet emboli are an infrequent and unique complication of penetrating trauma. Complications of venous and arterial bullet emboli can be devastating and commonly include limb-threatening ischaemia,pulmonary embolism, cardiac valvular incompetence, and cerebrovascular accidents. Bullets from penetrating wounds can gain access to the venous circulation and embolise to nearly every large vascular bed. Venous emboli are often occult phenomenon and may remain unrecognised until migration leads to vascular injury or flow obstruction with resultant oedema. The majority of arterial emboli present early with end-organ or limb ischaemia. We describe four separate cases involving venous bullet embolism and the subsequent management of each case. Review of the literature focusing on the reported management of these injuries, comparison of techniques of management, as well as the evolving role of endovascular techniques in the management of bullet emboli is provided.

Conservative management of retained cardiac missiles: case report and literature review

Intracardiac foreign bodies may be caused by direct penetrating trauma, embolization from injury to another area of the body, or iatrogenically from fragments of intravascular access devices. Penetrating cardiac trauma commonly presents with a hemodynamically unstable patient necessitating emergent life-saving procedures. Missile embolization to the heart can occur after injury to systemic and pulmonary veins. Central venous access devices may fracture after placement and embolize. Especially in the setting of penetrating cardiac trauma, these intracardiac foreign bodies require expeditious removal. Limited data exist regarding the conservative management of intracardiac material after trauma. We present the case of a 42-year-old male soldier injured in a mortar blast in Iraq who suffered multiple injuries to include a right hemopneumothorax and soft tissue injuries to the chest and both lower extremities that was found to have a 2-cm by 2-mm intracardiac metal fragment. Additional imaging revealed a metallic fragment localized to the interatrial septum. The patient suffered no adverse sequelae from nonoperative management. A review of the world literature regarding the subject of posttraumatic retained cardiac missiles (RCMs) is also included to help future surgeons in the management of this rare entity.

Pulmonary bullet embolism - a safe treatment strategy of a potentially fatal injury: a case report

BACKGROUND

Vascular embolization of a projectile discharged from a weapon is a rare event. In this report a hunter's errant gunshot struck a farmer in the left chest.

CASE REPORT

The projectile was lodged between the apex of the heart and the diaphragm. The patient was treated non-operatively and was discharged home only to return to the emergency department with chest pain and subsequent identification of the projectile in the left inferior pulmonary vein. Operative management consisted of a median sternotomy, cardiopulmonary bypass, and a pulmonary venectomy.

CONCLUSION

He was subsequently discharged home and recovered uneventfully.

[Intracardial migration of a bullet: diagnosis and management]

Venous pellet embolism to the cardia after shotgun wound is a very rare occurrence. Number and size of pellets, at the impact make this migration easier; embolism is asymptomatic and may occur 15 years after the injury. Many problems must be mentioned: mechanics of entry into the heart (own velocity, venous flow), topographic diagnosis (chest X-ray, transthoracic, transoesophageal ultrasound and CT-scan), local outcomes of this projectile (local erosion, clot, endocarditis), destination of a new migration (pulmonary embolism, left heart), indications of extraction, supervision. Extraction musn't be systematic, but only in the event of a patent foramen ovale with a risk of systemic embolism, which clinical outcomes are most serious or in the event of complications. The authors report on a 22 years old patient observation whose treatment was abstention and supervision.

Femoral artery embolus post-appendicectomy in a 12-year-old boy

A 12-year-old male presented with an acutely ischaemic leg following a laparotomy for a pelvic abscess secondary to acute appendicitis. A femoral angiogram revealed an embolus at the popliteal artery. Urgent embolectomy was performed with restoration of normal arterial flow. Subsequent investigation revealed a patent foramen ovale. We believe this case represents a paradoxical embolus from a primary pelvic vein thrombosis dislodged at the time of laparotomy.