Elsevier

Injury

Volume 42, Issue 5, May 2011, Pages 441-446
Injury

Review
The Evolving Management of Venous Bullet Emboli: A case series and literature review

https://doi.org/10.1016/j.injury.2010.08.006Get rights and content

Abstract

Bullet emboli are an infrequent and unique complication of penetrating trauma. Complications of venous and arterial bullet emboli can be devastating and commonly include limb-threatening ischaemia, pulmonary embolism, cardiac valvular incompetence, and cerebrovascular accidents. Bullets from penetrating wounds can gain access to the venous circulation and embolise to nearly every large vascular bed. Venous emboli are often occult phenomenon and may remain unrecognised until migration leads to vascular injury or flow obstruction with resultant oedema. The majority of arterial emboli present early with end-organ or limb ischaemia. We describe four separate cases involving venous bullet embolism and the subsequent management of each case. Review of the literature focusing on the reported management of these injuries, comparison of techniques of management, as well as the evolving role of endovascular techniques in the management of bullet emboli is provided.

Introduction

Penetrating gunshot wounds present a wide range of unique injury patterns. Commonly, by ascertaining the anticipated tract of the projectile, reasonable estimates of the associated injuries may be predicted. Although rare, bullet emboli present an exception to the predicted injury pattern and pose a challenging diagnostic and therapeutic dilemma. Intravascular bullet migration through the arterial or venous circulation has been sporadically reported in the literature. Due to the relative scarcity of this event, no management guidelines are universally accepted. It is generally agreed that arterial emboli should be extracted and both open and endovascular techniques have been used. Venous emboli are usually asymptomatic with the majority of those reported lodging in the right heart or pulmonary arterial tree. Management guidelines for venous emboli are less uniform and both extraction and observation have been described.26, 46 Evolution of endovascular techniques for bullet extraction has anecdotally decreased morbidity by decreasing the need for thoracotomy, sternotomy and cardiopulmonary bypass, previously required for operative access and removal of centrally lodged bullet emboli. We present four cases of venous bullet embolism and their subsequent management from level one trauma centres in an attempt to better characterise the treatment and diagnosis of these challenging injuries.

Section snippets

Case 1

A 22-year-old male presented after sustaining a large calibre gunshot wound to the left chest. The patient was alert, responsive, and haemodynamically stable at presentation but appeared pale and diaphoretic. He had undergone needle decompression of his chest in the field secondary to decreased left-sided breath sounds. Upon presentation, a left-sided thoracostomy tube was inserted with evacuation of 700 ml of blood. A chest X-ray revealed clear lung fields bilaterally and a foreign body in the

Discussion

The first case report of foreign body embolus is attributed to Thomas Davis in 1834 and involved not a bullet, but a wooden fragment embolising from the venous circulation to the right ventricle.7 Sporadic case reports have followed in the literature. The diagnosis of bullet embolism is often difficult and is commonly the result of one of three observations. First, an incongruent number of entry and exit wounds without intra-operative or radiographic confirmation of the presence of the bullet

Conflict of interest statement

None declared.

References (49)

  • P.A. Adegboyega et al.

    Arterial bullet embolism resulting in delayed vascular insufficiency: a rationale for mandatory extraction

    J Trauma

    (1996)
  • S.K. Agarwal et al.

    Wandering bullet embolizing to the pulmonary artery: a case report

    Asian Cardiovasc Thorac Ann

    (2007)
  • O. Berkan et al.

    An unusual case of birdshot embolism

    Circ J

    (2002)
  • U. Bertoldo et al.

    Retrograde venous bullet embolism: a rare occurrence-case report and literature review

    J Trauma

    (2004)
  • I.M. Best

    Transfemoral extraction of an intracardiac bullet embolus

    Am Surg

    (2001)
  • N. Bett et al.

    Delayed presentation of right ventricular bullet embolus

    Heart

    (2004)
  • H.J. Bining et al.

    Venous bullet embolism to the right ventricle

    Br J Radiol

    (2007)
  • V. Bors et al.

    Bullet embolization from the left brachiocephalic vein to the right ventricle

    J Card Surg

    (2008)
  • J.M. Breeding et al.

    Bullet embolus to the heart after gunshot wound to the neck: a case report

    Am Surg

    (2007)
  • J.J. Chen et al.

    MDCT diagnosis and endovascular management of bullet embolization to the heart

    Emerg Radiol

    (2007)
  • I.W. Colquhoun et al.

    Venous bullet embolism: a complication of airgun pellet injuries

    Scott Med J

    (1991)
  • H. Corbett et al.

    Paradoxical bullet embolus from the vena cava: a case report

    J Trauma

    (2003)
  • B. Cujec et al.

    Positive end-expiratory pressure increases the right-to-left shunt in mechanically ventilated patients with patent foramen ovale

    Ann Intern Med

    (1993)
  • A.F. de Andrade et al.

    Intracerebral bullet embolism: a rare cause of ischemic stroke

    J Neurosurg

    (2008)
  • Cited by (62)

    • The traveling pelvic bullet: a case of retrograde ballistic migration through the venous system

      2022, Journal of Vascular Surgery Cases, Innovations and Techniques
      Citation Excerpt :

      Traditionally, the enthusiasm for removing arterial bullets greater owing to concerns for distal ischemia. The answer to the question of venous injuries, which constitute only ∼20% of bullet embolus cases,10,11 is less clear. In 1987, Shannon et al12 described a case of bullet removal from a hepatic vein and reviewed 102 cases of venous bullet embolism in the preceding 57 years.

    • Anterograde venous bullet embolism from the left facial vein to the right ventricle

      2021, Trauma Case Reports
      Citation Excerpt :

      Venous bullet embolism makes up around 20–25% of known cases [1,3]. Sites of initial venous penetration include the transverse sinus, external jugular vein, brachiocephalic vein, superior vena cava, subclavian vein, axillary vein, internal iliac vein, external iliac vein, common iliac vein, and inferior vena cava [1,3–7]. Most venous bullet emboli migrate in an anterograde fashion (i.e., in the direction of blood flow) and up to 83% eventually travel to the right heart chambers, where they can become trapped in the myocardium or lodged in the distal branches of the pulmonary arterial tree [3].

    View all citing articles on Scopus
    View full text