The Case of the Elusive Oscillating Bullet Embolus and Its Ultimate Jailing

Abstract

<h3>Introduction and Objective</h3> Intravascular missile embolus is a rare, but potentially morbid, result of penetrating trauma. Herein, we present the case of a 43-year-old man with a single ballistic injury to the left hip, resulting in an isolated injury to the iliac wing, entry into the lumen of the left common iliac vein, and an embolic course to the atriocaval junction. The missile subsequently and repeatedly migrated to a variety of locations in the venous system. The oscillating behavior of the bullet and its ultimate endovascular management demonstrates a novel scenario which may be applicable in the treatment of future patients. <h3>Methods and Case Management</h3> A 43-year-old man, presented to our department trauma center with an isolated gunshot wound to the left hip. Initial plain films of the pelvis and abdomen were obtained revealing the absence of a radiopaque ballistic fragment. A plain film of the chest and contrasted cross-sectional imaging soon after revealed the bullet at the atriocaval junction. There were no observed viscous or solid organ injury. Additional imaging studies, temporally spaced, demonstrated the fragment that was then situated in the right pelvis (Figure 1a, 1b, 1c). The ballistic fragment continued to oscillate from the atriocaval junction to the right pelvis as demonstrated on serial plain films. In a hybrid operating theater with fluoroscopic capability, venogram revealed the bullet to be lodged in the right internal iliac vein (Figure 1c). After unsuccessful attempts at snaring the missile, the decision was made to stent across the ostia of the internal iliac vein and trap the missile in place. Sizing was performed using intravascular ultrasound and an 18 × 40 mm Wallstent was successfully deployed to jail the bullet (Figure 1d,1e). <h3>Results</h3> Completion venography demonstrated good result with the bullet excluded. The patient was discharged home on post-operative day two at follow-up 4 months later, he was found to be asymptomatic and doing well. The bullet remains in the right hemipelvis on subsequent imaging studies. <h3>Conclusion</h3> While the occurrence of bullet emboli has not become common enough to have standardized management, the option to trap intravascular ballistic fragments with an endovascular approach, may be a safe alternative compared to more invasive open intervention.