Hybrid treatment of bullet embolism at the abdominal aortic bifurcation, complicated with thoracoabdominal aorta pseudoaneurysm and common iliac artery occlusion: case report

Abstract

Embolization due to a firearm projectile entering the bloodstream is a rare event that is unlikely to be suspected during initial treatment of trauma patients. We describe and discuss a case of bullet embolism of the abdominal aortic bifurcation, complicated by a pseudoaneurysm of the thoracoabdominal aorta and occlusion of the right common iliac artery, but successfully treated using a combination of endovascular methods and conventional surgery.Keywords: gunshot wounds; embolism; aorta. ResumoA embolização por projétil de arma de fogo na circulação sanguínea é rara e de difícil suspeição no atendimento inicial ao trauma. Relatamos e discutimos um caso de embolia em bifurcação aórtica abdominal complicada com pesudoaneurisma de aorta tóraco-abdominal e oclusão de artéria ilíaca comum direita, tratada de forma efetiva pelos métodos endovascular e cirúrgico convencional.Palavras-chave: ferimentos por arma de fogo; embolismo; aorta.

Arterial bullet embolism after thoracic gunshot wound

“…According to a literature review, 10 from the first case of a projectile embolus, reported in 1834, up to 1990, approximately 160 cases had been reported. 2 Morais Filho et al 5 found a total of 20 reported cases of arterial embolism since 1990, involving 23 occluded arteries. The arteries most often involved in these embolisms were the lower limb arteries (11 out of 22 cases, 50%).…”

“…The site of impaction depends on the projectile caliber and vessel diameter and mainly occurs at vascular bifurcations, because they have sudden reductions in caliber. 1 , 2 , 4 Other contributory factors may include the patient's position following wounding, respiratory and hemodynamic activity, and gravity. 11 , 12 The vessel most commonly occluded in arterial bullet embolism is the femoral artery (30 to 50% of cases).…”

“…11 , 12 The vessel most commonly occluded in arterial bullet embolism is the femoral artery (30 to 50% of cases). 2 , 4 Additionally, the left leg is more commonly involved than the right, because of the smaller angle between the left common iliac artery and the aorta. 11 , 13 , 14…”

“…A bullet embolus should be suspected in the absence of an exit wound, 2 , 12 when there is radiological evidence of the presence of a bullet in unusual anatomic sites, without any relationship to the entrance wound, and/or where radiographic evidence does not correspond to the expected bullet trajectory. 2 , 4 , 6 Migration usually occurs soon after the missile enters the circulation, but it can also occur days, weeks, or even years later. 3 , 4 , 6…”

“…Projectiles have been reported to migrate within arterial and venous circulation, resulting in life-threatening injuries from the initial injury as well as from the migration event. 1 , 2…”