Transthoracic retrograde venous bullet embolism: case report and review of the literature

CASE REPORT

Transthoracic retrograde venous bullet embolism: case report and review of the literature

Alexandre de Tarso Machado^I; Ricardo Jayme Procópio^I; Francesco Botelho Evangelista^I; Gustavo Henrique Dumont Kleinsorge^II; Cristina Toledo Afonso^III; Túlio Pinho Navarro^IV

^IPhysician, Vascular and Endovascular Surgery Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, (UFMG), Belo Horizonte, MG, Brazil.

^IIResident, Vascular Surgery, Hospital das Clínicas, UFMG, Belo Horizonte, MG, Brazil.

^IIIResident, General Surgery, Hospital das Clínicas, UFMG, Belo Horizonte, MG, Brazil.

^IVPhD. Head, Vascular and Endovascular Surgery Service, Hospital das Clínicas, UFMG, Belo Horizonte, MG, Brazil.

ABSTRACT

Bullet embolism is a rare event when providing care to traumatized patients. These cases usually present with few symptoms or are asymptomatic, and treatment is controversial, in spite of the evolution observed. The endovascular approach has stood out as a treatment modality for this type of embolism with low morbidity and mortality rates. This article reports the case of a 30-year-old male patient victim of gunshot thorax injury with multiple entrance signs who was successfully submitted to bullet removal by endovascular technique after failed attempt by thoracotomy.

Keywords: Treatment, embolism, bullet.

RESUMO

Êmbolo balístico é um fenômeno de ocorrência rara no atendimento ao traumatizado. Geralmente, são pouco sintomáticos ou assintomáticos, e o tratamento desses pacientes, apesar de estar em constante evolução, é ainda controverso. A abordagem endovascular tem se destacado como modalidade de tratamento para esse tipo de embolia com baixa morbimortalidade. Este artigo relata o caso de um paciente de 30 anos, do sexo masculino, vítima de ferimento por arma de fogo com múltiplos orifícios de entrada em tórax, submetido com sucesso à retirada do projétil por acesso endovascular após tentativa frustrada de retirada por toracotomia.

Palavras-chave: Tratamento, embolia, projétil.

Introduction

The first case of vascular embolism caused by foreign body was described by Davis in 1834 in a child with a fragment of wood embolized into her heart.¹ Since then there have been several reports in the literature of other types of materials related to post-traumatic or iatrogenic embolism, such as needles, catheter tip, metallic fragments, and firearm bullets.^1-12

Bullet embolism is a rare phenomenon in firearm trauma. Its occurrence is related to periods of war and social violence.^2-4

Patients are mostly asymptomatic. Clinical manifestations, when present, are influenced by factors such as bullet location and presence of thrombotic, ischemic or hemorrhagic complications. Finding the bullet location using imaging examinations before and during surgery is important for diagnostic and therapeutic definition. Treatment of these patients, despite being in continuous progress, is still controversial. The endovascular approach had stood out as a treatment modality for this type of embolism.

Case description

A 30-year-old man, victim of firearm trauma, had multiple bullets in the thoracic region.

He was admitted with patent airways, tachycardiac, dyspneic, reduced respiratory sounds bilaterally, hypovolemic shock, and lowered awareness level (Glasgow 9/15). Replacement of blood volume was performed using saline solution and bilateral thoracic drainage.

The patient had entry holes in the thoracic paravertebral regions bilaterally, exit hole in the left posterior axillary line, and transfixing lesion in the left upper limb. Thoracic tomography showed a bullet in the cardiac apex, which led to indication of surgical treatment. He was submitted to sternotomy, in which no external heart injury was found. The bullet was palpable in the right ventricle. In the intraoperative period there was an accidental displacement of the bullet, which made its removal not feasible. A simple intraoperative chest x-ray identified the bullet in the topography of the retrohepatic vena cava, which motivated interruption of the surgery.

Later, the bullet was located in the pelvis using a new abdomen x-ray (Figure 1). An endovascular treatment was then chosen, which was performed 10 days after the trauma.

In the intervention, using the venous access of the right common femoral vein, pelvic phlebography identified the bullet lodged in the right internal iliac vein (Figure 2).

The bullet was captured using a basket catheter (), which was then retracted until the puncture site (Figure 3). Surgical access was performed via femoral vessels and transverse phlebography with bullet removal, followed by phleborrhaphy. He was discharged on the third postoperative day.

Discussion

Bullet embolism should be considered in patients that have entry bullet hole with no corresponding exit hole in cases in which the bullet is not seen in x-rays at the expected location.^4,5

Patients are asymptomatic in about 70% of cases.^1,6Symptoms, when present, depend on embolus location and association with complications such as pain, dyspnea, asthenia, hemorrhage, thrombosis, arrhythmias, valve dysfunction, endocarditis, sepsis, erosion or vascular occlusion.^3,4,7,8_.

Intravascular penetration of the bullet can be a result of direct injury to the heart or to other vascular sites.⁹ After penetration, the bullet may migrate by intravascular pathway, which usually occurs immediately after the trauma. However, migration 14 years after the event has been described. Other authors described migration during surgery, as in the present case report. Such migration is dependent on factors such as embolus weight, speed, size and shape, patient's position, gravity action, muscle and respiratory movements, vascular anatomy and flow speed of affected vessel.^3,7,10

Bullet displacement can be caused by low speed and small bullet diameter, involving pulmonary or systemic circulation through the venous or arterial system.⁹

The level of impact depends on embolus and vessel diameter and mainly occurs in vascular bifurcations, since they are sites of abrupt diameter reduction. The most commonly occluded vessel in arterial embolism is the femoral artery (30-50% of cases).^3,11,12

In this case, the bullet was initially found in the right ventricle, and it may be assumed that it had entered the heart by a branch of the pulmonary artery, and not by a direct injury, since during surgical exploration there were no external heart injuries. Manipulation during the surgery caused the bullet to migrate, following retrogradely toward the retrohepatic vena cava and posteriorly toward the right common iliac vein.

Imaging methods to locate the bullet, such as simple x-ray, computed tomography, echocardiography or arteriography are essential for diagnostic confirmation and treatment planning.³ These exams are important in the preoperative period to show a possible embolus migration during patient manipulation.⁹

There are controversies in the literature as to treatment of bullet embolism. However, most authors recommend conservative treatment in asymptomatic patients, indicating surgical embolus removal in case of symptoms or possibility of complications, such as embolization into risk areas. The patient described in this case had no symptoms directly related to embolism, but there was possibility of complications, such as deep venous thrombosis or pulmonary embolism, which justified surgical treatment.

Choice of surgical procedure is based on the exact location of the bullet and on the patient's clinical status. Among the varied treatment modalities available, endovascular surgery has been increasingly more used due to its advantages in relation to open surgery, such as use of local anesthesia and lower morbidity and mortality rates.^3,4,7-9 Endovascular surgery has also been considered as the first treatment option for moving emboli. Percutaneous removal using basket or snare is the most frequently used technique. ¹¹ Endovascular treatment using a basket catheter was successfully used in the case reported herein.

Conclusion

Bullet embolism is a rare event that should be considered in cases of trauma caused by firearm in which there is no exit hole for the bullet and when it is not identified by simple x-ray in the expected location. Most of the time, they are asymptomatic and only require conservative treatment, but can be appropriately treated by minimally invasive techniques with low morbidity and mortality rates whenever necessary.

References

• 1. Nagy KK, Massad M, Fildes J, Reyes H. Missile embolization revisited: a rationale for selective management. Am Surg. 1994;60:975-9.
• 2. Starling SV, Maia E, Drumond DAF. Embolo balístico na artéria pulmonar. Trauma. 2007;10:73-98.
• 3. Demirkilic U, Yilmaz AT, Tatar H, Ozturk OY. Bullet embolism to the pulmonary artery. Interact Cardiovasc Thorac Surg. 2004;3:356-8.
• 4. Cysne E, Souza EG, Freitas E, et al. Bullet embolism into the cardiovascular system. Tex Heart Inst J. 1982;9:75-80.
• 5. Duncan IC, Fourie PA. Embolization of a bullet in the internal carotid artery. AJR Am J Roentgenol. 2002;178:1572-3.
• 6. Chen JJ, Mirvis SE, Shanmuganathan H. MDCT diagnosis and endovascular management of bullet embolization to the heart. Am Soc Emergency Radiol. 2007;14:127-30.
• 7. Padula RT, Sandler SC, Camishion RC. Delayed bullet embolization to the heart following abdominal gunshot wound. Ann Surg. 1969;169:599-602.
• 8. Symbas PN, Harlaftis N. Bullet emboli in the pulmonary and systemic arteries. Ann Surg. 1977;185:318-20.
• 9. Actis Dato GM, Arslanian A, Di Marzio P, Filosso PL, Ruffini E. Posttraumatic and iatrogenic foreign bodies in the heart: report of fourteen cases and review of literature. J Thorac Cardiovasc Surg. 2003;126:408-14.
• 10. Saltzstein EC, Freeark RJ. Bullet embolism to the right axillary artery following gunshot wound of the heart. Ann Surg. 1963;158:65-9.
• 11. Bertoldo U, Enrichens F, Comba A, Ghiselli G, Vaccarisi S, Ferraris M. Retrograde venous bullet embolism: a rare occurrence-case report and literature review. J Trauma. 2004;57:187-92.
• 12. Garzon A, Gliedman M. Peripheral embolization of a bullet following perforation of the thoracic aorta. Ann Surg. 1964;160:901-4.

Correspondence

Publication Dates

• Publication in this collection
  20 Feb 2009
• Date of issue
  Dec 2008

History

• Received
  27 Aug 2008
• Accepted
  14 Oct 2008