Associated projectile inferior vena cava wound with subsequent pulmonary artery missile embolization: a case report and literature review

Abstract

A rare and unpredictable complication of firearm and missile injuries is projectile embolism. With only a few cases described in the literature, bullet embolism may become a diagnostic challenge for emergency physicians and military surgeons. Bullet embolization is a rare phenomenon, but the complications can be devastating. Case presentation. A 34‑year‑old man sustained a severe complex abdominoskeletal mine‑blast injury with damage to the hollow organs (duodenum and transverse colon), inferior vena cava and both low extremities. The internal hemorrhage was stopped by phleborrhaphy. The wounds of the duodenum and large intestine were sutured, and gunshot fractures of both anticnemions were stabilized by extrafocal osteosynthesis. The whole‑body CT showed that there was a projectile embolus into the branch of the right mid‑lobe pulmonary artery. No clinical manifestations of pulmonary artery embolism were observed in the patient. After surgery, he developed multiple necrosis and transverse colon perforations that resulted in fecal peritonitis. The suture line leakage that caused the formation of a duodenal fistula and postoperative wound infection were also detected. The complications were managed by multiple reoperations. The attempts of endovascular bullet extraction weren’t undertaken due to severe concomitant injuries, complications and asymptomatic clinical course of pulmonary artery projectile embolism. Open surgery retrieval of the embolus was successfully performed on the 80th day after injury. The patient was discharged from the hospital in good condition on the 168th day after the missile wound. Conclusions. Patients with missile wounds and no exit gunshot perforation should be examined using the whole‑body CT for determining possible migration of a projectile with the blood flow. Patients with asymptomatic pulmonary artery embolism should be managed nonoperatively. In case of symptomatic pulmonary artery projectile embolism, it is reasonable to consider the possibility of open thoracic surgery.