1. Retrograde Embolization
of Retrained Bullet After Gunshot
Wound to Right Ventricle
Jamaica Westfall-Snyder, B.S.; Eric Pittelkow, MD; Andres
Fajardo, MD; Katie Stanton-Maxey, MD
Indiana University School of Medicine, Division of Trauma
Surgery
3. Introduction
• Penetrating trauma from GSWs can present a
challenging situation in identifying the
projectile’s trajectory and damaged organs
and tissues involved
• Clinical judgement based on previous trauma
data is often used to determine the
management of these projectiles: Remove or
Not
4. Introduction
• We present a case report and discussion of
available literature on retrograde venous
embolization of a bullet fragment after a
gunshot wound
5. Case Presentation
• 23-year-old African American male presented
to emergency department after sustaining a
single gunshot wound to the right lateral chest
with no exit wound.
• Initial evaluation: shock
– Hypotensive, tachycardic, diaphoretic
– Decreased breath sounds bilaterally
– GCS 13
6. Case Presentation
• Interventions
– Large bore peripheral IV
– Massive transfusion protocol initiated
– FAST exam: pericardial effusion
– Patient transferred to operating room
7. Operating Room
• Median sternotomy: right hemothorax and tense pericardium
• Opened pericardium findings: penetrating injury to right
ventricle
– Foley catheter to control bleeding
– Right ventricle wound repaired
– No bullet on examination
– No additional full thickness injuries
• Pericardium reexamined demonstrated no additional wounds
8. Fluoroscopic Exam Findings
• Radio opaque object
located in right pelvis
• Lateral view localized
object to the level of
the anterior vertebral
bodies of the lumbar
spine
9. Operating Room Continued
• Midline laparotomy performed
– No blood encountered upon entry
– Retroperitoneal hematoma absent
– Negative for additional injuries
– Palpable mass posterior to right iliac artery
• Vascular surgery consultation
14. Recovery
• Patient transferred to surgical intensive care unit
– Transesophageal echocardiogram performed
• Ejection Fraction: 60%
• No intra-cardiac injuries
• No wall motion abnormalities
• Patient extubated post-op day 1
• Chest tube removed post op day 5
• Discharged home post op day 6
15. Discussion
• Bullet embolization is a difficult diagnosis
–Rare complication GSW
– Presentation varies widely
• Arterial bullet embolization can present with
dramatically apparent findings of ischemia
• Venous embolization may be clinically silent
16. Discussion
• Categories of Bullet Embolization
– Arterial: high pressure system, congruent with
physiologic flow
• Most frequent type of bullet embolization
• 80% are symptomatic
– Venous: low pressure system, can oppose
physiologic flow
• 66% asymptomatic at presentation
17. Discussion
• Outcomes of venous embolization can be
devastating
– Thrombosis
• Pulmonary Embolism
• Stroke
– Infection
• Sepsis
• Thrombophlebitis
• Endocarditis
– Cardiac complications
• Arrhythmias
18. Discussion
• High level of suspicion
– No exit wound exists
– Radiographic images are negative for bullet in vicinity of
wound
– Bullet migration on serial images
19. Discussion: Treatment
Recommendations
• No consensus reached on management of
venous bullet embolization
• Difficulty in defining a treatment algorithm
– Decreased prevalence
– Limited experience at single center
– Time of presentation
– Presence of absence of symptoms
21. Literature Review
• A review of 102 cases, published in The Journal of Trauma
– Shannon et al used time of presentation to guide therapeutic approach in
their article Venous bullet embolism: rational for mandatory extraction: 1987
• <6 weeks: remove; >6 weeks + asymptomatic: observation
– Pseudointimal covering
• Most common embolus related complications: pulmonary abscess or
infarction, stroke, extremity thrombophlebitis
– Not removed: 25% (13/51) embolus related complication; 6% fatality
– Removed: 2% (1/51) embolus related complication
• Combined risk: ≥ 10%
• Stable patient immediate post injury phase: Early extraction
• Delayed recognition: consider size, shape, location, potential
contamination, and projectile contour
22. Literature Review
• Miller et al published a case
report and literature review
in Injury: International
Journal of Care in the Injured
in 2011
– 45 cases of venous bullet
embolization
– Management:
• 14/45 careful observation
• 26/45 extraction
– Importance of anatomic
destination of emboli
23. Conclusion
• While surgical judgment in the present case prompted the
removal of the bullet fragment, the current literature
is limited on best practice for venous bullet embolization.
• The largest study reviewed in this presentation recommends
extraction of the bullet fragments if less than 6 weeks from
injury, and observation if more than 6 weeks from injury
in asymptomatic.
• More recent study suggests the location of the venous bullet
embolization is of greater significance
24. References
1.Makramalla, A., et al., Bullet retrieval from the right hepatic vein using a controlled
endovascular and transhepatic approach. Radiol Case Rep, 2018. 13(5): p. 940-944.
2.Nolan, T., et al., Bullet embolization: multidisciplinary approach by interventional radiology and
surgery. Semin Intervent Radiol, 2012. 29(3): p. 192-6.
3.Toscano, L., D. Terra, and S. Salisbury, Femoral Embolization after Cardiac Gunshot. Case Rep
Emerg Med, 2018. 2018: p. 7969845.
4.Busada, M., Y. Maldonado, and Q. Zhang, Retrograde Venous Bullet Embolization to the Hepatic
Inferior Vena Cava Located with Intraoperative Transesophageal Echocardiography. CASE (Phila),
2018. 2(2): p. 59-62.
5.Kortbeek, J.B., J.A. Clark, and R.C. Carraway, Conservative management of a pulmonary artery
bullet embolism: case report and review of the literature. J Trauma, 1992. 33(6): p. 906-8.
6.Shannon, F.L., et al., Venous bullet embolism: rationale for mandatory extraction. J Trauma,
1987. 27(10): p. 1118-22.
7.Miller KR, Benns MV, Sciarretta JD, Harbrecht BG, Ross CB, Franklin GA, et al. The Evolving
Management of Venous Bullet Emboli: A case series and literature review. Injury 2011;42:441–6.
doi:10.1016/j.injury.2010.08.006.
Editor's Notes
23-yo AA male presented to ED after sustaining a single gunshot wound to the chest without an exit wound. Patient was in shock and had a GCS of 13.
ATLS performed..fast exam revealed a pericardial effusion and patient was transferred to the OR
((As intubation would cause ventricles to collapse intubation was postponed as long as possible))
Median sternotomy revealed a right hemothroax and tense pericardium which was opened. penetrating injury to the RV was found. Bleeding was controlled with a foley catheter while the RV was repaired with 3-0 prolene. No bullet present nor any additional full thickness injuries. The pericardium was re-examined and no additional were found.
Fluoroscopic exam was performed and located bullet in right pelvis
Midline laparotmy was negative for blood upon entry or other injuries. But was positive for a palable mass posterior to the right iliac artery. Vascular surgery was consulted.
An intraoperative venogram demonstrated an obvious fillign defect in the right common iliac vein.
Venotomy was performed and the bullet was delivered through the incision for extraction.
((Here you can see the obvious mushrooming of the bullet.))
After surgery pt transferred to surgical ICU, the following morning TEE showed normal EF and no cardiac issues
POD 1 pt was extubated, POD 5 chest tube removed, and POD 6 he was discharged to home.
Bullet emboliztion is a difficult diagnosis. It is not only a rare complication GSW but also presentation varies widely as arterial emboliztion frequently presentes with apparent findigns of ischemia and venous embolization can be clincally silent
Arterial embolisms occur in a high pressure system and travel congruent to physiologic flow. These are the most common type of bullet embolization. Venous emoblizations occur in a low pressure system and can oppose. Majority of these are asymptomatic at presentation
Venous embolization can have devastating outcomes including thrombotic complications of PE and stroke, infective issues of sepsis, thrombophelbitis, and endocarditis. other cardiac complications include arrhythmias
Diagnosis requires high level of suspicion especially when no exit wound exists, imaging is negative for the bullet in the expected vacinity, or serial imaging demonstrates migration of the missile
There is not yet a consenses for management of venous bullet embolization. Decreased prevelence, limited exposure at a single center, and variability in both time of presenation and presence or absence of symptoms maeks this difficult.
In determining whether to remove the bullet or observe it is important to consider the time of presentation and presence or absence of symptoms
The journal of trauma published a review of 102 cases from 1930-1987 and used time of presentation to delineate treatment because after 6 wks the psudointimal covering should have incorporated the missile into the vessel wall.
Of the cases reviewed there was a higher incidence of complications in those who did not receive immediate removal with 25% having an embolus related complication as oppose to the early removal population in which a single patient had a PE
They found that for those presenting with immediate recognition, extraction is superor
However in delayed recognition, numerous factors must be considered.
In the Injury: international journal of care of the injured, a review of 45 cases of venous bullet embolization was publisehd in 2011.
30% treated with careful observation.
marjoity = asymptomatic patients with embolization to pulmonary artery.
Authors highlighted the imporance of anatomic destination of the emboli, advocating for use of embolic location to determine removal or observation.
