Left pulmonary artery bullet embolism following a penetrating cardiac gunshot injury

Abstract

Introduction Bullet emboli occur when bullets migrate from an entry point to an abnormal endpoint via blood vessels or bowel. Most result from low-velocity, small calibre civilian gunshots. Although rare, when it does occur, it commonly embolises to the arterial system. Many times, these are amenable to removal and recovery. Case report We present a case of a haemodynamically unstable polytrauma patient with a pulmonary artery projectile embolus following a penetrating trans-thoracic cardiac gunshot wound. Conclusion A brief overview of the literature regarding bullet emboli is provided in light of this unusual case, focusing specifically on thoracic bullet emboli. A high index of suspicion should be raised when the number of entry and exit wounds are incongruent, bullet location does not align with anticipated trajectory, or serial radiographs demonstrate missile migration. Radiological evaluation and bullet retrieval are dependent on haemodynamic stability of the patient.

Pulmonary bullet embolism following cardiac gunshot wound: case report of a bullet that traversed the heart twice

“…The reported cases of pulmonary bullet embolism have mostly followed lesions of peripheral veins without concomitant cardiac involvement [8]. Cardiac gunshot wounds subsequently complicated by migration of bullets into the pulmonary arteries are reportedly rare [2,8,9]. Following trans-thoracic gunshot wound, the bullet in the index case penetrated the RA and made two migrations thereafter.…”

“…Besides the diameter of the bullet and its velocity, entrance profile and path of the bullet inside the body are important as well as the biological characteristics of the injured organ. Most high velocity bullets enter and leave the body in a straight trajectory while low velocity bullets may divert through bones or soft tissues and remain lodged, or may yet penetrate vessels, cardiac walls [1], or bowel [2] and behave as bullet emboli (BE) [3].…”

“…The first instance of a traumatic projectile embolism was published by Thomas Davis in 1834, when he reported a case of a wooden fragment that embolized from the venous circulation to the right ventricle in a 10-year old boy [3][4][5]. Bullet embolus to the pulmonary artery was first reported by Moresten in 1903 (Moresten cited in [2]). Bullet embolism is a rare phenomenon in trauma [6], with only 300 cases published before 2011 [4].…”

“…Bullet emboli are either arterial (75%) or venous (20%). Very occasionally, BE may pass from veins to arteries (or vice versa) through a traumatic arteriovenous fistula (AVF) or an intra-cardiac communication [2,4,7]. Such (paradoxical) BE constituted 2.4% of emboli in Springer et al's review (Springer et al cited in [4]) while they reached 5% in other reports [2,7].The phrase "venous bullet emboli" refers to emboli to the right heart or pulmonary arteries [7].…”

“…Migration of bullets into the pulmonary artery is described most often with lesions of peripheral veins without concomitant cardiac involvement [8]. Gunshot wounds of the heart with migration of the bullet into the pulmonary artery are rare [2,8]. Herein, we present a very rare case of bullet embolism from the right atrium (RA) to right internal iliac vein and back to right heart and left pulmonary artery in which the patient survived trans-thoracic extraction of the bullet from left lower pulmonary lobar artery.…”