‘Bullet embolism’ to the popliteal artery following air rifle injury of the thoracic aorta

Abstract

There has been an increase in the incidence of air gun and air rifle pellet injuries. Hutchinson' reviewed 36 injuries in children over a 2-year period and found that half were trivial and none was serious, but Shaw and GalbraithZ emphasized the danger of intracranial air gun pellet wounds. In a recent review of missile-induced vascular trauma in Northern Ireland3 no case of bullet embolus was recorded. We report an air rifle pellet injury to the chest, with peripheral embolism to the popliteal artery. Case reportA 14-year-old boy was brought to the Accident Department of the Bristol Royal lnfirmary having been shot by an 0.22 air rifle pointed directly at him from a distance of 8 yards. He had collapsed immediately after the injury, but rapidly recovered and was able to walk. Chest pain and minimal dyspnoea were his only symptoms. On physical examination his haemodynamic state was stable. An entry wound was found overlying the left second costal cartilage with tenderness and soft tissue swelling. No foreign body was palpable, there was no exit wound, and chest radiographs, both PA and lateral failed to demonstrate any radio-opaque foreign body or haemopneumothorax. Peripheral pulses were palpable in all limbs.The wound was explored under general anaesthesia since it was felt that the pellet might be lying behind the sternum, but exploration behind the sternum and upper costal cartilages on the left side did not reveal any foreign body. A localized haematoma was noted in the upper mediastinum.Immediately after this procedure the peripheral pulses were re-examined. The left dorsalis pedis pulse was absent and the left foot felt cold. A repeat chest radiograph now showed some widening of the mediastinum, and a plain radiograph ( Figure I ) of the left leg demonstrated a pellet lodged in the region of the left popliteal artery.The chest was explored through a left anterolateral thoracotomy. There was a penetrating wound through the upper lobe of the left lung passing in between the arch ofthe aorta and the left pulmonary artery. running down in the adventitial layer of the descending aorta for about 2 cm before entering the lumen. Once identified, this was repaired by interrupted buttressed prolene sutures. The left popliteal fossa was explored concurrently through a medial incision, and a pellet removed from the distal popliteal artery through a small transverse arteriotomy. DiscussionThe earliest recorded case of 'bullet embolism' in 1834 was cited by Sir John Bland-Sutton in 19194 and in a general review he commented that penetrating bullet wounds of the aorta were not always fatal. Bullets entering the aorta migrate to the left leg three times more often than to the rights. perhaps as a result of the less acute angulation of the leR common iliac artery. Barratt6 supported Bland-Sutton's observation and also emphasized that in these cases clinical evidence of migration was seldom noted during the initial clinical examination.In a series of28 patients with major vessel injuries from gun shot wounds treated over a ...

Popliteal artery bullet embolism in a case of homicide: a case report and review of the tangible literature

“…Schowengerdt et al [40] presented a case in which an airgun pellet penetrated through the right ventricle, interventricular septum, and anterior papillary muscle and was ejected from the left ventricle, being found and removed from the left popliteal artery with restoration of flow. The similar case of popliteal artery embolism but after airgun penetration through the thoracic aorta, was reported by Burkitt et al [41]. The popliteal artery bullet embolism was previously presented in two relatively older articles [42,43].…”

Air weapon injuries: a serious and persistent problem

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“…A 30-year-old man sustained a gunshot wound to the left Hank on May5, 1988, and was admitted with a distended abdomen, hypoactive bowel sounds, left lower quadrant tenderness, and gross blood on rectal examination. BothSurgeryMarch 1990 Schematic summary of emboli to upper extremities and thoracic aorta from cases reported in the literature.…”