Bullet Embolism Research Articles

Successful mechanical thrombectomy for terminal ICA bullet embolism: A case report

Bullet embolism after high velocity penetrating trauma is a rare event that can have devastating and wide-ranging effects distant from the original site of injury. A 29-year-old presented with multiple gunshot wounds to the chest, back, abdomen, and lower extremities but no penetrating head injury. After proper resuscitation, the patient was noted to have left-sided hemiparesis and computed tomography angiography of the head showed a bullet fragment that had traveled to the right M1 segment of the middle cerebral artery resulting in occlusion of the vessel. Mechanical thrombectomy was performed in an attempt to remove the bullet fragment but this was unsuccessful as the fragment was firmly lodged in the blood vessel. Aspiration of clot distal to the fragment was then performed in hopes of preventing a large volume ischemic event which was angiographically successful resulting in TICI 2c revascularization. This case demonstrates that thrombectomy can be safely and successfully performed distal to a lodged foreign body.

Intracardiac foreign bodies: Diagnosis and management

<b>Introduction:<i> </i></b>As a result of gunshot wounds due to a bullet or shrapnel entering the system of arteries or veins, direct wounds of the heart or vascular structures, as well as embolisms may occur. After entering one of the systemic veins, the bullet or shrapnel can enter the right heart or the pulmonary artery. Shrapnel embolism is a rare condition, usually asymptomatic and is detected accidentally during routine examinations. Due to the fact that the intensity of occurrence of this type of cases is quite rare, it was decided to present such clinical cases.<br /> <b>Material and methods:<i> </i></b>This article reports about 3 patients with intracardiac foreign body. All 3 patients took part in the battles during the Second Karabakh War and were hospitalized as a result of shrapnel wounds received in different parts of the body. In each of the patients, the lesion area was different, but as a result of venous migration, the movement of a foreign body (metal fragment) in the heart cavity was noted. In two patients, the foreign body was removed by open surgery (connection to a heart-lung machine) due to the presence of symptoms, but one patient was under observation due to the absence of symptoms.<br /> <b>Results:<i> </i></b>Bullet or shrapnel embolism is a very rare complication of gunshot wounds, occurring in about 0.3% of cases. These emboli often cause antegrade migration into the arterial system. However, in about 20% of cases, migration into the venous system can also occur. Venous embolism often results in foreign body migration into the right heart or the pulmonary artery. The diagnosis in these cases is often established by chance, but in some cases, arrhythmias and valve defects can occur due to exposure to a foreign body. The identification of such cases depends on the symptoms. A foreign body can be removed by an open method, as well as by invasive methods. In some cases, it is possible to keep the foreign body under control when it does not cause any symptoms.<br /> In the clinical cases we mentioned, we also mentioned the management of cases of foreign bodies entering the venous system from peripheral zones of penetration.

Management of Venous and Arterial Bullet Emboli.

Gunshot wounds account for significant morbidity and mortality in the United States. A rare and potentially fatal complication of a gunshot wound is bullet embolus. Potential complications include distal limb ischemia, coronary infarct, renal infarction, stroke, pulmonary embolization, cardiac valvular injury, thrombophlebitis, and dysrhythmias. Overall, surgical embolectomy and endovascular retrieval are the preferred treatments for bullet emboli. We report one case of venous bullet embolus and one case of arterial bullet embolus, both of which were successfully treated with endovascular retrieval. A thorough physical exam and appropriate imaging are vital to prompt identification and treatment of bullet emboli, as the repercussions of missed injuries can be devastating.

Venous bullet embolism to the right ventricle: Case report

It is extremely rare for venous-injured gunshot wounds to cause cardiac embolism. Removal of cardiac embolism is essential in these patients. But there are also cases where it is not possible to remove the pellet for various reasons. In this case report, we aimed to present a case that we followed without removing pellets that did not damage important heart structures.

Gunshot Wound to the Right Superior Pulmonary Vein With Bullet Embolization to the Aortic Bifurcation: Emergent Surgical Repair.

Bullet embolization is a rare complication of gunshot wound injuries with most of the literature consisting of case reports. We report a case regarding bullet embolization to the distal aorta following entry into the right superior pulmonary vein as a result of a gunshot wound to the posterior chest. The patient presented with signs of lower extremity ischemia. Imaging revealed an intrabdominal bullet at the level of L4 and laparatomy identified the bullet to be within the aorta at the bifurcation. Successful repair of the cardiac injury and removal of the intra-aortic bullet were achieved by sternotomy and laparatomy.

Simultaneous retrograde venous and anterograde arterial bullet embolism: a case report

BackgroundBullet embolus is a rare condition following gunshot injuries and represents a clinical challenge regarding both diagnosis and management.Case presentationWe report the case of a 35-year-old Iranian (Middle-Eastern) male patient with a shotgun injury to both buttocks, which traveled to the heart and the popliteal area through the femoral vein and superficial femoral artery, respectively. Surgical intervention was applied for the popliteal pellet, and the patient was discharged without further complications.ConclusionAlthough bullet emboli can be a clinical challenge, with the advent of modern procedures, removal has become safer. X-ray, computed tomography, and transthoracic and/or transesophageal echocardiography may be used as adjuncts to help establish the diagnosis.

A Lost Bullet in the Coronary Sinus: A Cautionary Tale

AbstractWe present a case of venous bullet embolism to the right atrium following a gunshot wound (GSW) to the abdomen. A 53-year-old male presented after a GSW to the abdomen. His workup included a computed tomography (CT) scan demonstrating an aortic injury with aortocaval fistula. A radio-opaque object consistent with a bullet was visualized in the right atrium. First, this case details an important decision, choice of surgery versus an interventional approach. After repair of the aortocaval fistula, the patient underwent a planned attempt to extract the bullet through a right lateral thoracotomy approach utilizing cardiopulmonary bypass to facilitate a right atriotomy. Intraoperatively, the team was not able to localize the bullet in the right atrium despite fluoroscopic evaluation. A postoperative CT scan demonstrated that the bullet had migrated into the coronary sinus. Lastly, this case demonstrates successful positioning maneuvers to dislodge the bullet out of the heart and into the inferior vena cava, allowing for the endovascular extraction of the bullet.

Bullet Embolism into the Common Iliac Artery from a Gunshot Wound to the Heart.

We describe the management of bullet embolism from a penetrating cardiac injury, including the clinical, radiographic, and operative considerations in this challenging trauma scenario. Bullet embolism represents a rare but complex subset of ballistic penetrating trauma, and highlights the importance of radiographic correlation with intraoperative findings.

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

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.

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

<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.

A Magic Bullet: Bullet Embolism From the Heart to the Femoral Artery

A case study a patient who was emergently evaluated with an intraoperative transesophageal echocardiography after suffering a gunshot wound to the back is provided. This diagnostic examination revealed a left atrium to aorta fistula, due to the path of the bullet through the body. Immediate postoperative imaging with computed tomography revealed that the bullet had embolized to the left femoral artery from which it was later surgically removed. This rare clinical phenomenon of bullet embolization, involving the heart and associated vasculature, is reviewed.

Peripheral Venous Bullet Embolization To The Heart – A Case Study

A bullet embolism is a rare complication following penetrating gunshot injury which can present challenges in diagnosis and management. If the projectile has been unsuccessfully removed or remains left in situ, there is a risk that the missile may have gained access to the vascular system from where the flow of blood migrates the foreign body to any number of large vascular beds. Arterial embolization is more common and is often accompanied with symptoms associated with end-organ damage and peripheral ischemia. Venous embolization is less common with few, or no symptoms reported, unless vascular injury, pulmonary embolism or oedema related venous flow obstruction is experienced which may require urgent attention. We present the incidental findings of a bullet within the right ventricle following a gunshot injury to the right upper thigh eleven years prior. To our knowledge, this is the first reported incidence identified in the United Kingdom.

Invited Commentary: Key Concepts of CT for Penetrating Abdominopelvic Injuries.

Invited Commentary: Key Concepts of CT for Penetrating Abdominopelvic Injuries.

The wandering bullet: An unusual case of paradoxical embolization involving the neck, aortic arch, and iliac artery

Paradoxical intravascular bullet embolism involving the aortic arch (AA) is a rare and highly lethal condition. We describe an unusual case of a civilian gunshot injury to the neck. A bullet entered in the neck, injured the internal jugular vein (IJV), and then continued into the lumen of the common carotid artery (CCA). The bullet traveled under its own momentum and against the flow of blood, along the carotid and brachiocephalic vessels, finally lodging in the wall of the lesser curvature of the AA. The injury tract resulted in an arterial-venous fistula between IJV and CCA and a pseudoaneurysm of the AA. Open surgical repair of the neck and AA was complicated by secondary distal embolization of the bullet, requiring an embolectomy.

Pulmonary Artery Bullet Embolization: Presentation and Management.

Pulmonary Artery Bullet Embolization: Presentation and Management.

Conservative management of unusual bullet embolism in the internal iliac vein

Conservative management of unusual bullet embolism in the internal iliac vein

Pulmonary bullet embolism following cardiac gunshot wound: case report of a bullet that traversed the heart twice

BackgroundCardiac gunshot wounds with bullet embolism (BE) into the pulmonary artery are rare. Most pulmonary BE follow injuries of peripheral veins without concomitant cardiac injury. Herein, we describe a case of cardiac gunshot injury in which the bullet migrated from right atrium through the inferior vena cava down to right internal iliac vein and back to the left pulmonary artery. Such bullet migration is too rare and unusual and to our knowledge not reported before.Case presentationOn March 4, 2019, a man of 39 had a bullet injury during celebratory gunfire. He was clinically stable with entrance on right posterior chest but no exit. Chest CT scan showed a bullet in the right atrium. The next day, the bullet migrated to the right pelvis as shown by plain chest and pelvic radiographs. CT angiography 3 weeks afterwards displayed the bullet in the right internal iliac vein. Meanwhile, the patient was asymptomatic, thus discharged home. However, 3 months later, he was readmitted because of chest pain, dyspnea, and sweating. A repeat chest CT scan showed the bullet in the left lower lobe pulmonary artery. Hence, pulmonary BE was suspected and eventually a 0.36 bullet was removed via left thoracotomy.ConclusionsThis is a case of symptomatic venous BE with typical diagnostic criteria (a small low-velocity bullet with inlet but no exit located away from anticipated trajectory with migration proven by serial radiographs). Endovascular removal was preferred but was not available. BE of the heart is exceedingly rare. Hence, diagnosis requires a high degree of clinical awareness.

Retrograde venous bullet embolism into renal vein

The unpredictable nature and behaviour of bullet emboli can pose unique diagnostic and management challenges, related to the absence of exit wounds or variable trajectories. However, embolisation into the vascular system is an extremely unusual occurrence, with fewer than 200 such cases described since 1900. Given the relative paucity of such literature reports, it is not surprising that guidelines for the optimal management of some of these emboli are neither clear cut, nor universally accepted. We report the second case of retrograde venous bullet embolism to the right renal vein following a gunshot injury to the right chest and the surgical solution.

Radiation diagnostics of thoracic gunshot wounds

The frequency of thoracic injuries in the general structure of combat surgical trauma remains at the level of 7-12 % and unchanged from the time of the Second World War to the current armed conflicts. The overwhelming majority of them (up to 72 %) are shrapnel gunshot wounds. The formation of a gunshot wound occurs due to the action of a shock wave; a wounding projectile; energy of side impact and vortex wake. The shape, size, features of the wound canal are determined by the kinetic energy of the wounding agent and the physical properties of the damaged tissues. The lung parenchyma is loose and elastic, so small-caliber bullets with low energy cause minimal damage. The wound canal is well differentiated on CT-slices. Its cavity is filled with blood, fragments of destroyed tissue, air bubbles. On the periphery, the contusion zone is determined (area of increased attenuation in the lung-ground-glass opacity). Shrapnel wounds can be accompanied by ruptures of the pulmonary parenchyma with hemorrhages, bilateral pulmonary contusion, damage to the bone frame and soft tissues of the chest. Vascular injury with massive hemorrhage into the pleural cavity and tense hemopneumothorax are one of the main causes of mortality in penetrating wounds. Transmediastinal gunshot wounds, armor trauma and bullet embolism require special attention during radiation examination of victims. The purpose of radiation diagnostics of modern combat trauma is to identify and fully characterize injuries and their complications. The amount of diagnostic information is determined by the level of medical care. Key words: gunshot wounds, chest cavity organs, radiation diagnostics.

Combined shrapnel injury of the inferior vena cava which caused bulletpulmonary artery embolism (case report and review of the literature)

Bullet embolism is a rare and unpredictable complication of gunshot and mine‑explosive injuries. With only few cases described in the literature, bullet embolism may become a diagnostic challenge for emergency and military surgeons. Thus, bullet embolization is a rare phenomenon, the complications can be devastating.A clinical case of bullet embolism is described. 34‑years old man got combined abdominal‑skeletal mine‑explosive injuries with damage to hollow organs (duodenum and transverse colon), inferior vena cava and both low extremities. Internal bleeding was stopped by the inferior vena cava edge wound suturing. Wounds of duodenum and large intestine were sutured; gunshot fractures of both tibial bones were stabilized with external fixation devices. Computer tomography of the entire body showed the presence of embolus in the right middle lobe artery. Clinical manifestations of pulmonary embolism were not observed. The patients had several complications after surgery such as: multiple focal necrosis and perforations of transverse colon caused a fecal peritonitis; duodenum suture failure caused forming of a duodenal fistula; postoperative wound infection. These complications necessitated performing of multiple reoperations. Attempts of endovascular bullet extraction didn’t undertake because of severe concomitant injuries, its complications and asymptomatic clinical course of pulmonary artery projectile embolism. Open surgery removing of embolus was successfully performed in 80 days after injury. The patient was discharged from hospital in good condition in 168 days after gunshot wound. Patients with an explosive‑mine wound and gunshot wound with no exit should to be examined with whole‑body computer tomography for determining possible projectile migration with bloodstream. Patients with asymptomatic pulmonary artery embolism should to be managed non‑operatively in the early posttraumatic period. In case of symptomatic pulmonary artery bullet embolism is reasonable to consider of a possibility of an open thoracic surgery.