Associated projectile inferior vena cava wound with subsequent pulmonary artery missile embolization: a case report and literature review
DOI:
https://doi.org/10.30978/GS-2021-1-48Keywords:
missile wound, inferior vena cava, pulmonary artery, venous missile embolismAbstract
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.
References
Agarwal SK, Singh A, Kathuria M, Ghosh PK. Wandering bullet embolizing to the pulmonary artery: a case report. Asian Cardiovasc Thoracic Ann. 2007;15(2):154-6. DOI: 10.1177/021849230701500215.
Aidinian G, Fox CJ, Rasmussen TE, Gillespie DL. Varied presentations of missile emboli in military combat. J Vasc Surg. 2010;51(1):214-7. DOI: 10.1016/j.jvs.2009.06.054.
Bertoldo U, Enrichens F, Comba A, Ghiselli G, Vaccarisi S, Ferraris M. Retrograde venous bullet embolism: a rare occurrence — case report and literature review. JTrauma. 2004;57(1):187-92. DOI: 10.1097/01.ta.0000135490.10227.5c.
Colquhoun IW, Jamieson MP, Pollock JC. Venous bullet embolism: a complication of airgun pellet injuries. Scott Med J. 1991;36(1):16-7. DOI: 10.1177/003693309103600107.
Corbett H, Paulsen EK, Smith RS, Carman CG. Paradoxical bullet embolus from the vena cava: a case report. J Trauma. 2003;55(5):979-81. DOI: 10.1097/01.TA.0000028835.94166.68.
Carter CO, Havens JM, Robinson WP, Menard MT, Gates JD. Venous bullet embolism and subsequent endovascular retrieval — A case report and review of the literature. Int J Surg Case Rep. 2012;3(12):581-3. DOI: 10.1016/j.ijscr.2012.06.011.
Duke E, Peterson AA, Erly WK. Migrating bullet: A case of a bullet embolism to the pulmonary artery with secondary pulmonary infarction after gunshot wound to the left globe. J Emerg Trauma Shock. 2014;7(1):38-40. DOI: 10.4103/0974-2700.125638.
Ezberci F, Kargi H. Surgical management of a pulmonary artery missile embolism after an air rifle wound to the liver. South Med J. 1999;92(12):1207-9. DOI: 10.1097/00007611-199912000-00015.
Goldman RL, Carmody RF. Foreign body pulmonary embolism originating from a gunshot wound to the head. J Trauma. 1984;24(3):277-9. DOI: 10.1097/00005373-198403000-00018.
Fernandez-Ranvier GG, Mehta P, Zaid U, Singh K, Barry M, Mahmoud A. Pulmonary artery bullet embolism — Case report and reviewюInt J Surg Case Rep. 2013;4(5):521-3. DOI: 10.1016/j.ijscr.2013.02.017.
Hartzler GO. Percutaneous transvenous removal of a bullet embolus to the right ventricle. J Thorac Cardiovasc Surg. 1980;80(1):153-5.
Hiebert CA, Gregory FJ. Bullet embolism from the head to the heart. JAMA. 1974;229(4):442-3.
Hughes BD, Vender JR. Delayed lead pulmonary emboli after a gunshot wound to the head. Case report. J Neurosurg. 2006;105(3 Suppl):233-4. DOI: 10.3171/ped.2006.105.3.233.
Jackson CC, Munyikwa M, Bacha EA, Statter MB, Starr JP. Cardiac BB gun injury with missile embolus to the lung. J Trauma. 2007;63(4):100-4. DOI: 10.1097/TA.0b013e3181469ea7.
John LC, Edmondson SJ. Bullet pulmonary embolus and the role of surgery. Thorac Cardiovasc Surg. 1991;39(6):386-8. DOI: 10.1055/s-2007-1020007.
Khomenko I, Shapovalov V, Tsema I, et al. Hydrodynamic rupture of liver in combat patient: a case of successful application of «damage control» tactic in area of the hybrid war in East Ukraine. Surg Case Rep. 2017;3(1):88. DOI: 10.1186/s40792-017-0363-6DOI: 10.1097/00005373-199212000-00020.
Kortbeek JB, Clark JA, Carraway RC. Conservative management of a pulmonary artery bullet embolism: case report and review of the literature. J Trauma. 1992;33(6):906-8. DOI: 10.1097/00005373-199212000-00020.
Layton TR, Stroh AM, Villella ER. Missile embolus of the portal vein. J Trauma. 1985;25(11):1111-2.
Lichte P, Oberbeck R, Binnebösel M, Pape HC, Kobbe P. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med. 2010 Jun 17;18:35. DOI: 10.1186/1757-7241-18-35.
Lundy JB, Johnson EK, Seery JM, Pham T, Frizzi JD, Chasen AB. Conservative management of retained cardiac missiles: case report and literature review. J Surg Educ. 2009;66(4):228-35. DOI: 10.1016/j.jsurg.2009.04.002.
Marshall CD, Ma MR, Park J, et al. Recovery of a missile embolus from the right ventricle. Ann Thorac Surg. 2017;103(1):69-71. DOI: 10.1016/j.athoracsur.2016.06.107.
Mattox KL, Beall AC Jr, Ennix CL, DeBakey ME. Intravascular migratory bullets. Am JSurg. 1979;137(2):192-5. DOI: 10.1016/0002-9610(79)90143-0.
Mctyre E, McGill L, Miller N. Missile pulmonary embolus secondary to abdominal gunshot wound. Radiol Case Rep. 2012;7(3):709. DOI: 10.2484/rcr.v7i3.709.
Meeks T, Nwomeh B, Abdessalam S, Groner J.Paradoxical missile embolus to the right superficial femoral artery following gunshot wound to the liver: a case report. J Trauma. 2004;57(6):1338-40. DOI: 10.1097/01.ta.0000152311.84257.4d.
Michelassi F, Pietrabissa A, Ferrari M, Mosca F, Vargish T, Moosa HH. Bullet emboli to the systemic and venous circulation. Surgery. 1990;107(3):239-45.
Miller KR, Benns MV, Sciarretta JD, et al. The evolving management of venous bullet emboli: a case series and literature review. Injury. 2011;42(5):441-6. DOI: 10.1016/j.injury.2010.08.006.
Nagy KK, Massad M, Fildes J, Reyes H. Missile embolization revisited: a rationale for selective management. American Surgeon. 1994;60(12):975-9.
Nally L, Kahn SA, Jacobs I, Johnson MS, Bankey PE. Pulmonary artery missile embolus after a gunshot wound to the upper extremity. J Trauma Acute Care Surg. 2012;72(3):111. DOI: 10.1097/TA.0b013e3182198bce.
Nazir Z, Esufali ST, Rao NS, Rizvi I. Venous bullet embolism: a case report and review of the literature. Injury. 1992;23(8):561-3. DOI: 10.1016/0020-1383(92)90163-m.
Nehme AE. Intracranial bullet migrating to pulmonary artery. J Trauma. 1980;20(4):344-6.
Nolan T, Phan H, Hardy AH, Khanna P, Dong P. Bullet embolization: multidisciplinary approach by interventional radiology and surgery. Semin Intervent Radiol. 2012;29(3):192-6. doi: 10.1055/s-0032-1326928.
Patten ED, Morales HE. Bullet emboli to the pulmonary artery: a rare occurrence. J Trauma. 1982;22(9):801-2. DOI: 10.1097/00005373-198209000-00016.
Rich NM, Collins GJ Jr, Andersen CA, McDonald PT, Kozloff L, Ricotta JJ. Missile emboli. J Trauma. 1978;18(4):236-9. DOI: 10.1097/00005373-197804000-00002.
Sclafani SJ, Shatzkes D, Scalea T. The removal of intravascular bullets by interventional radiology: the prevention of central migration by balloon occlusion — case report. J Trauma. 199;31(10):1423-5. DOI: 10.1097/00005373-199110000-00022.
Schmelzer V, Mendez-Picon G, Gervin AS. Case report: transthoracic retrograde venous bullet embolization. J Trauma. 1989;29(4):525-7. DOI: 10.1097/00005373-198904000-00021.
Schurr M, McCord S, Croce M. Paradoxical bullet embolism: case report and literature review. J Trauma. 1996;40(6):1034-6. DOI: 10.1097/00005373-199606000-00034.
Shannon FL, McCroskey BL, Moore EE, Moore FA. Venous bullet embolism: rationale for mandatory extraction. J Trauma. 1987;27(10):1118-2.
Singer RL, Dangleben DA, Salim A, et al. Missile embolism to the pulmonary artery: case report and pitfalls of management. Ann Thorac Surg. 2003;76(5):1722-5. DOI: 10.1016/s0003-4975(03)00692-1.
Stephenson LW, Workman RB, Aldrete JS, Karp RB. Bullet emboli to the pulmonary artery: a report of 2 patients and review of the literature. Annals of Thoracic Surgery. 1976;21(4):333-6. DOI: 10.1016/s0003-4975(10)64322-6.
Symbas PN, Harlaftis N. Bullet emboli in the pulmonary and systemic arteries. Ann Surg. 1977;185(3):318-20. DOI: 10.1097/00000658-197703000-00012.
Unkle D, Shaikh KA. Iliac vein to pulmonary artery missile embolus: case report and review of the literature. Heart and Lung. 1988;17(4):363-5. .
Vanarsdell GS, Razzouk AJ, Fandrich BL, Shakudo M, Schmidt CA. Bullet fragment venous embolus to the heart: case report. J Trauma. 1991;31(1):137-9. DOI: 10.1097/00005373-199101000-00027.
Yamanari MG, Mansur MC, Kay FU, Silverio PR, Jayanthi SK, Funari MB. Bullet embolism of pulmonary artery: a case report. Radiol Bras. 2014;47(2):128-30. DOI: 10.1590/S0100-39842014000200018.
