Systematic review of civilian intravascular ballistic embolism reports during the last 30 years

Right hepatic vein bullet embolism: A case report

Penetrating trauma is usually divided into stab and gunshot wounds (GSW). When considering GSW, the initial assessment involves the identification of all the wounds, to understand the projectile's trajectory as well as to determine which anatomic structures might have been damaged [1]. Rarely, the projectile might not leave the victim's body and embolize to a different region through large blood vessels. Known as Missile Embolism (ME), this uncommon complication can compromise multiple body segments, resulting in severe injuries, whether it occurs through an artery or a vein, such as pulmonary embolism, cardiac-valve incompetence, limb-threatening ischemia, coronary infarct, and stroke [2,3]. This is a case report of an 18-year-old male patient who suffered a gunshot wound and was submitted to an exploratory laparotomy which identified a laceration of the inferior vena cava. Further exams concluded that the bullet was embolized to the right hepatic vein. ME treatment will depend mostly on the bullet's placement; if located in the left circulation or arterial vessels, retrieval is the preferred treatment. It can be executed through surgical exploration or endovascular procedure [3,4,8] Venous ME has several treatment options, including conservative management if the patient remains asymptomatic [[3], [4], [5], [6], [7]]. Cases of paradoxical embolization might be managed as arterial ME [3,4].

Case report - Embolic shotgun pellet to the right internal carotid artery causing hemiplegia

INTRODUCTION AND IMPORTANCE

Intravascular ballistic embolism is a rare and complex medical condition, posing diagnostic and management challenges. It involves the migration of ballistic materials within the arterial system, often stemming from neck and chest injuries.

CASE PRESENTATION

A 13-year-old boy sustained a chest injury from an air rifle, leading to a pellet embolism in the right internal carotid artery, resulting in severe cerebral infarction. Despite intervention attempts, the lodged pellet left the patient with permanent hemiplegia.

CLINICAL DISCUSSION

Intravascular ballistic embolism, although infrequent, presents diagnostic and therapeutic complexities. Embolization can manifest after a delay, with neck and chest injuries serving as common entry points. This case raised potential embolization routes through the left ventricle or a chest wound to the aortic arch or right common carotid artery. Management strategies for intravascular ballistic embolism remain debated. Some cases are conservatively treated, while others undergo surgical or radiological procedures to remove the foreign body. These interventions carry risks, such as foreign body migration and reperfusion injury.

CONCLUSION

Effectively managing intravascular ballistic embolism necessitates a deep understanding of possible embolization routes and a careful evaluation of intervention risks. Collaborative research efforts are pivotal in establishing optimal management strategies for these intricate cases.

A Lost Bullet in the Coronary Sinus: A Cautionary Tale

We 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.

Air rifle wound to the chest and pellet embolism to the intracranial internal carotid artery with a middle cerebral artery territory infarct: A case report and review of literature

INTRODUCTION

Traumatic embolization of pellets into the cerebral circulation is a rare complication following gunshot wounds to the neck, chest and abdomen. Foreign bodies enter the circulation from early direct puncture or delayed erosion of an artery or vein or directly through the heart.

PRESENTATION OF CASE

A previously well 13-year-old Sri Lankan boy who presented 2 h following an air rifle injury to the lower sternum with chest pain, developed seizures and left hemiparesis. Contrast CT angiogram showed the pellet at the base of the skull at the right carotid canal, with a middle cerebral artery (MCA) thrombus and evidence of MCA infarction. Decompressive craniectomy was performed. Cerebral angiography confirmed complete occlusion of the intracranial internal carotid artery (ICA) by the pellet, without cross circulation from the left ICA. Attempts at endovascular pellet retrieval failed. Open pellet embolectomy was not performed and the patient was managed conservatively.

DISCUSSION & CONCLUSION

Air rifle injury to the chest causing pellet embolism from the left ventricle to the right intracranial ICA with associated right MCA thrombus is a rare phenomenon. Missile embolism must be suspected when neurological findings are not in concordance with the site of injury especially in the absence of an exit wound and an inability to locate the pellet in the vicinity of the entry wound. Radiographs, CT and cerebral angiography are indicated to locate the pellet and associated injuries. The decision on surgical embolectomy, endovascular retrieval or expectant management is an individualized decision dependent on many factors.

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.

Bullet embolism to the heart secondary to gunshot wound of the left subclavian vein: A case report

Missile embolism as a consequence of gunshot wounds is a rare occurrence, and can lead to severe complications such as endocarditis, pulmonary thromboembolism and arrythmias. The correct diagnosis of bullet embolism can be challenging in an emergency care setting, often requiring a combination of clinical, radiological and surgical resources. The management of a venous missile embolism depends on characteristics such as size and location of the projectile, and must be highly individualized for each patient. In this report, a case of bullet embolism to the heart in a patient who suffered a gunshot wound to the left subclavian vein provides a backdrop for the discussion of the diagnosis and treatment of this rare ballistic injury.

Management of intracardiac bullet embolisation and review of literature

Vascular injury is a common complication in firearm injuries; however, intravascular missile embolism is relatively rare. There are only 38 documented cases of intravascular missile embolisation to the heart. Bullet embolisms are difficult to diagnose even with multiple diagnostic modalities and even once identified, the most optimal choice of surgical management is debated. Our patient presented with a gunshot wound to the right posterior shoulder. Cardiac focused assessment with sonography for trauma, chest X-ray, CT and echocardiogram were performed, showing missile location adjacent to the right ventricle with inconclusive evidence of pericardial injury. Exploratory median sternotomy was performed, revealing intact pericardium and injury to the superior vena cava (SVC) with bullet embolisation to the right ventricle. The patient became temporarily asystolic secondary to haemorrhage from the SVC injury. Cardiac massage was performed, dislodging the missile into the inferior vena cava. A venotomy was performed to retrieve the bullet and vascular injuries were primarily repaired.

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.

Right ventricular shotgun pellet embolism: Case report and radiological aspect

Pellet embolism to the heart following gunshot injuries is an unusual event that requires a fast diagnosis. Imaging assessment is necessary to locate the projectiles and look for associated injuries. We present a case of a 41-year-old woman admitted after sustaining 2 gunshot wounds in the abdomen and left thigh, with the initial computed tomography (CT) scan showing a metallic object next to the right ventricle. Further radiological evaluation included transthoracic echocardiography and electrocardiogram-gated cardiac CT scan which confirmed the diagnosis of a migrating pellet to the right ventricle, entrapped within the trabeculations. Electrocardiogram-gated cardiac CT has a major role in detailed evaluation of bullet embolism to the heart cavities and guides the management.

Multiple sites bullet embolism as a cause of acute abdomen

Bullet embolism (BE) is a rare and misdiagnosed phenomenon that can significantly affect the cardiovascular system. It occurs when a bullet enters and migrates through the body vessels in gunshot victims. We report in this article a case of a 25-year-old male patient, victim of penetrating trauma caused by a firearm projectile that presented two embolism destinations with acute ischemic repercussions: the right brachial artery and the branches of the superior mesenteric artery. We quickly performed surgical exploration to assess the level of ischemia and resect the foreign body. To the best of the authors' knowledge, this is the only case of acute vascular abdomen due to BE in the literature. There is no standard treatment for BE, and each case should be studied according to signs and symptoms while considering the risks of the destination vessel for the victim. Imaging is necessary for early diagnosis, and the medical team must be aware of multiple and extraordinary critical ischemia presentations when bullet trajectory suggests embolism.

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.

Venous bullet embolism to the right ventricle: Case report and review of management

Intravascular missile emboli to the right heart should be retrieved surgically if the risk of surgical complication due to sternotomy and cardiotomy is low. Endovascular retrieval is another possible method of extraction to be considered.

Embolic Shotgun Pellet to the Left Middle Cerebral Artery Causing Hemiplegia and Aphasia With Near Complete Clinical Recovery on Nonoperative Management

A 28-year-old male presented after gunshot injury to his right side from a shotgun. He had no prior history of gunshot injury and no neurologic deficits on presentation. Initially, non-contrast computed tomography (CT) scans of the head, face, chest, abdomen, and pelvis demonstrated multiple pellets lodged in the patient’s right upper extremity, face, abdomen, and right hemithorax which penetrated the right lung. A shotgun pellet was also found in the region of the left middle cerebral artery (MCA) on the head CT without contrast with no skull fracture or intracerebral hemorrhage. The patient subsequently developed right hemiplegia and expressive aphasia approximately 48 hours after the trauma. CT angiography (CTA) of the head and neck with perfusion at that time demonstrated ischemic penumbra and the location of the pellet to be in the distal left M1 branch. No intervention was performed given the location. The patient clinically improved without intervention. This is an uncommon injury and outcome for embolization of a foreign body.

Ischaemic Stroke Caused by a Gunshot Wound to the Chest

Introduction

Pneumatic weapons rarely cause severe trauma. However, pellet embolisation can cause severe and unexpected injuries.

Report

This is the case study of a 32 year old man, who was shot in the chest with a pneumatic rifle. Initially, urgent damage control surgery was performed to resolve pneumothorax and pericardial tamponade, but no projectile was found. Subsequent atypical symptomatology led to more extensive imaging that found a pellet embolised into the right carotid artery, thrombosis of the middle cerebral artery, and development of a large right hemispheric ischaemic area. After an unsuccessful endovascular intervention, the projectile was removed during an open surgical procedure. The right hemisphere oedema required decompressive hemicraniectomy, but long term intensive care and physiotherapy resulted in a satisfactory recovery with moderate neurological sequelae.

Conclusion

An unusual clinical presentation in combination with an absent exit wound might be symptomatic of projectile embolisation and should lead to a search for it. When the projectile position is convenient, surgical removal is the treatment of choice while an endovascular approach should be reserved for inaccessible locations or asymptomatic cases.

•

Projectile embolisation can lead to severe and unexpected pathologies.

•

Unusual clinical signs and an absent exit wound are suspicious of embolisation.

•

For symptomatic emboli, urgent projectile removal is necessary.

•

Surgical rather than endovascular removal is preferred for symptomatic emboli.

Fatal cardiac injury sustained from an air gun: Case report with review of the literature

•

Air guns use compress air to cause bullet acceleration and can cause serious injury.

•

Cardiac injuries from air guns are rare, but can lead to cardiac tamponade/death.

•

Published cases of cardiac injuries from air guns most commonly occur in children.

Introduction

Traditionally promoted as “toy guns,” air guns have long been used by children and lack many regulatory guidelines compared to conventional firearms. However these weapons possess serious lethal potential and have led to numerous injuries and deaths.

Presentation of case

We describe a 21 year old man who sustained a penetrating cardiac wound from a pellet gun that led to cardiac tamponade and death. Post-mortem examination showed the pellet had penetrated the left ventricle and anterior esophagus with subsequent intraluminal migration into the stomach.

Discussion

Review of the literature identified 39 other cases of penetrating cardiac injuries from air guns. Sternotomy was the most frequently used surgical approach and the right and left ventricles were the most commonly affected chambers. Bullet embolization was the most frequently reported complication. Including our case, five deaths related to penetrating cardiac injury from air guns were identified.

Conclusions

This report highlights the seriousness of air guns and demonstrates a unique intra-thoracic injury.

Non-thrombotic pulmonary embolism in emergency CT

Non-thrombotic pulmonary embolism (NTPE) results from the embolization of non-thrombotic materials. It can often be a challenging diagnosis due to non-specific (similar to thrombotic pulmonary embolism) or uncommon clinical and imaging findings. Patients with NTPE often present to the emergency department with acute respiratory distress, and contrast-enhanced computed tomography (CT) of the chest and CT pulmonary angiography are the imaging modalities of choice for respiratory distress. Since the treatment of NTPE is entirely different from thromboembolism, its distinction is essential. Moreover, early diagnosis of NTPE is necessary. Radiologists must be familiar with the diagnostic findings of NTPE, and this article aims to review the imaging features of various causes of NTPE.