BULLET EMBOLI: A PERPLEXING PROBLEM

Objectives: Gunshot wounds (GSW) account for significant morbidity and mortality in the United States. A rare and potentially fatal complication of GSW is a bullet embolus (BE). The incidence of actual BE was reported as 0.04% during the Vietnam war and 0.3% during the Afghanistan war (1,2). BE can be subdivided into arterial, venous, and paradoxical (3). Arterial embolism can result in distal limb ischemia, coronary infarct, renal infarction and stoke. Venous embolism can result in pulmonary embolization, cardiac valvular injury, thrombophlebitis, and dysrhythmias (4,5). A thorough physical exam and appropriate imaging is vital as the repercussions of missed injuries can be devastating. The incidence of arterial BE was estimated to be four times venous BE but more recently seen to be equal (1,5). We have one case of venous BE and one of arterial BE to report.
A 25 year-old male sustained a single GSW to the anterior right chest. The patient required a right tube thoracostomy and blood transfusion with improved hemodynamics. His CT imaging demonstrated a right hemopneumothorax, a grade 5 liver injury with probable intrahepatic inferior vena cava injury. The missile found in the left external iliac vein, remote from the hepatic injury. Repeat imaging revealed migration of the ballistic missile to the right upper quadrant of the abdomen. The patient underwent successful percutaneous retrieval of the missile, which was found to be in the right renal vein. He did well, chest tube was removed and discharged post-injury day 3 with aspirin. A 25 year-old female sustained a single GSW to the left back. She was hemodynamically normal and CXR unremarkable with no missile found. Right femoral and pedal pulses were absent. A CT chest/abdomen/pelvis revealed a left hemothorax and the missile in the right external iliac artery. The patient underwent a left tube thoracostomy and the bullet was removed percutaneously with a TEVAR placed over the aortotomy. She did well, chest tube was removed and discharged post-injury day 5 with aspirin.
BE are a rare sequelae of GSWs with potentially devastating complications. Prompt recognition and management are essential in preventing significant morbidity and mortality. The importance of physical exam and appropriate imaging to account for all missiles fired is imperative. The rule of even number of wounds and missiles must be followed. In hemodynamically normal patients, these missiles can often be treated with minimally invasive and percutaneous techniques.

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