Objectives: Upon completion of this article, the reader will be able to (1) explain the incidence and potential complications of bullet embolization, and (2) recall the challenge of diagnosing this entity and the therapeutic possibilities available including endovascular retrieval. Accreditation: Tufts University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit: Tufts University School of Medicine designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Case PresentationA 46-year-old man presented to a local level 2 trauma center after sustaining a single gunshot wound to the right upper quadrant of the abdomen. The patient was hemodynamically unstable and was taken emergently to the operating room for exploration of the abdomen. He was found to have a through and through injury to the liver, small intestinal injury at two locations, and a single injury to the infrarenal vena cava. The Keywords ► penetrating trauma ► bullet embolization ► endovascular retrieval ► interventional radiology AbstractBullet embolization after penetrating trauma is an infrequent but important phenomenon. It presents an unexpected sequelae to the otherwise predictable injury pattern of penetrating missile injury mechanism and poses a challenging diagnostic and therapeutic dilemma. Bullets from penetrating wounds can gain access to the vasculature and migrate to nearly every large vascular bed. Patients can be asymptomatic, but the potential complications can be devastating including limb-threatening ischemia, sepsis, endocarditis, cardiac valvular incompetence, pulmonary embolism, stroke, and even death. The exact incidence of bullet embolization is unknown, but it was estimated to be 0.3% during the Vietnam War and 1.1% in the recent conflict in Afghanistan and Iraq. The scarcity of the condition and the lack of concentrated experience at any single institution contribute to the controversies pertaining to the management approach. Traditionally, surgical extraction of embolized bullets may involve difficult and invasive surgical exposures. Recent advancement in endovascular techniques provides an additional option in this treatment algorithm. In this article, we describe a case of venous bullet embolization from the left iliac vein treated by a combined endovascular and surgical approach.

Background: The emphysema interventional treatment involves mainly lung volume reduction surgery (LVRS) and endobronchial valve (EBV) implantation. Few institutes discuss these cases at a dedicated emphysema multidisciplinary team (MDT) meeting. Objectives: To investigate the impact of a newly established dedicated emphysema MDT meeting on the interventional treatment of such patients. Methods: During a study period of 4 years, the outcome of 44 patients who underwent intervention according to the proposal of the emphysema MDT (group A) was compared with the outcome of 44 propensity score matched patients (group B) treated without the emphysema MDT proposal. Results: More LVRS and less EBV insertions were performed in group A ( P = .009). In group B, the interventions were performed sooner than in group A ( P = .003). Postoperative overall morbidity and length of in-hospital stay were similar in the 2 groups ( P = .918 and .758, respectively). Improvement of breathing ability was reported in more patients from group A ( P = .012). In group B, the total number of re-interventions was higher ( P = .001) and the time to re-intervention had the tendency to be less ( P = .069). Survival was similar between the 2 groups ( P = .884). Intervention without discussion at the MDT and EBV as initial intervention was an independent predictor of re-intervention. Conclusions: Interventional treatment for patients with chronic obstructive pulmonary disease (COPD) after discussion at a dedicated MDT involved more LVRS performed, required fewer interventions for their disease, and had longer re-intervention-free intervals and better breathing improvement.

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The authors report a case of a 19-year-old man with a Segond fracture with knee effusion after an acute injury, in addition to findings of prior anterior cruciate ligament (ACL) reconstruction. This case illustrates the predictive nature of Segond fracture for further acute meniscoligamentous injury, even after previous ACL reconstruction.