Abstract
Acute upper limb ischemia caused by a gunshot penetrating vascular injury and subsequent arterial embolization by foreign body is uncommon in everyday practice and is associated with high morbidity/mortality rates, especially with emergency surgery. We present the case of a 72-year old male who attempted suicide using a gun. A gunshot entry wound was evident in the right upper chest region with no pellet exit wound. Radial pulses were palpable bilaterally. Angiography revealed right subclavian artery direct injury and pellet embolization to the brachial artery. The patient underwent open surgery, with reversed saphenous vein interposition graft to replace subclavian artery defect. A pellet was removed by a separate arteriotomy in the brachial artery. Associated injuries were clavicle-comminuted fracture and subclavian vein injury. The patient remained well 5 months later with no reported complications. In conclusions, the presence of radial pulses alone on clinical exam cannot rule out the presence of a significant vascular injury.
Highlights
IntroductionPenetrating vascular injuries are associated with high mortality rates, with a significant percentage of patients dying before reaching the hospital [1] [2]
Acute upper limb ischemia caused by a gunshot penetrating vascular injury and subsequent arterial embolization by foreign body is uncommon in everyday practice and is associated with high morbidity/mortality rates, especially with emergency surgery
The presence of radial pulses alone on clinical exam cannot rule out the presence of a significant vascular injury
Summary
Penetrating vascular injuries are associated with high mortality rates, with a significant percentage of patients dying before reaching the hospital [1] [2]. Gunshot vascular injuries may be associated with bone, nerve and muscu-. As patients with intra-arterial pellet migration may be asymptomatic, because of a good collateralization, this may delay diagnosis and subsequently result in poor outcomes. According to Feliciano D.V. et al, patients after penetrating trauma, presenting with symmetrical pulses and normal ABPI, should be discharged and followed-up. 1% - 4% of these asymptomatic patients eventually undergo surgery [4]. We report a rare case of a pellet embolization to the right brachial artery after right upper chest gunshot injury. To the best of our knowledge, this is the first case report addressing pellet embolization to the brachial artery
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