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CASE REPORT  
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 218-221
Missile embolism from pulmonary vein to systemic circulation: Case report with systematic literature review


Department of General Surgery, Goa Medical College, Bambolim, Goa, India

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Date of Submission22-Apr-2019
Date of Acceptance16-Jun-2019
Date of Web Publication27-Aug-2019
 

   Abstract 


Missile embolism (ME) is a rare condition and was seen in 0.3% of gunshot wounds during the Vietnam War. It was first reported by Thomas Davis in 1834. ME occurs when a small caliber, slow velocity projectile penetrates a wall in the vasculature; loses its kinetic energy; and gets carried away along the bloodstream to occlude another vessel at a distant site. Civilian victims of low-velocity bullets account for 60% of such cases. ME can be arterial, venous, or paradoxical. Systemic arterial embolization accounts for 80% of published reports and occurs after the projectile penetrates the left chambers of heart, aorta, or very rarely pulmonary veins (PVs). There are only nine published reports of ME through PV till date. We report here, embolism of an air-gun pellet entering through the right thorax, into right PV, embolizing into right femoral artery, causing acute limb ischemia, in a young male. Emergency arteriotomy and removal of the embolic pellet saved the limb with good recovery. He did not require a thoracotomy. The clinical picture, radiological findings, operative details, and the management are presented and discussed with relevant literature. The purpose of this report is to highlight the unique presentation of ME through PV, as its management is different from other cases of arterial ME. Early diagnosis of the condition is imperative to prevent permanent ischemic damage of end organ and its sequelae. We present an analysis of all published reports of systemic ME through PV and also give our recommendations for its management.

Keywords: Air gun pellet, bullet embolism, femoral artery embolism, pulmonary vein embolism, thoracic gunshot injury

How to cite this article:
Govindaraju RC, Kolwalkar JP. Missile embolism from pulmonary vein to systemic circulation: Case report with systematic literature review. J Emerg Trauma Shock 2019;12:218-21

How to cite this URL:
Govindaraju RC, Kolwalkar JP. Missile embolism from pulmonary vein to systemic circulation: Case report with systematic literature review. J Emerg Trauma Shock [serial online] 2019 [cited 2019 Sep 21];12:218-21. Available from: http://www.onlinejets.org/text.asp?2019/12/3/218/265386





   Introduction Top


Missile embolism (ME) from gunshot injuries is rare and <200 cases have been reported till date.[1] Civilian low-caliber, low-velocity pellets account for 80% of cases of ME.[2],[3]

ME is classified as arterial, venous, or paradoxical.[4],[5],[6],[7] Systemic arterial ME can occur when the missile enters through the left cardiac chambers, aorta, or pulmonary veins (PVs). The entry of a missile through PV is extremely rare with only nine published reports. We report here, embolism of an air gun pellet entering through the right thorax, through the right PV, into the right femoral artery causing acute limb ischemia in a young male. Emergency arteriotomy and removal of the embolic pellet saved the limb, and the patient had good recovery. The clinical picture, radiological findings, and the management are discussed along with relevant literature.


   Case Report Top


A 23-year-old male sustained multiple air gun pellet injuries to the right upper and lower limbs and right anterior chest and was brought to our hospital after 10 h. He complained of acute onset right lower limb pain with impaired sensation and inability to move the limb. On examination, he was hemodynamically stable with absent right lower limb pulses with features of acute ischemia.

There were 4 entry wounds of which 3 had accountable pellets on clinical and radiological evaluation. The fourth puncture wound was over the right anterior chest wall at the 6th intercostal space 1 cm lateral to mid-clavicular line without any exit wound or a clinically evident pellet nearby. The chest radiograph showed minimal right hemothorax, no pneumothorax, normal cardiac outline, and no pellet. Radiograph and ultrasound examination of the abdomen was normal.

Computed tomography (CT) of the thorax showed pellet trajectory [Figure 1] toward right hilum along with linear contusion of the right lower lobe and minimal right hemothorax with no visible pellet. Two-dimensional (2D) echocardiography showed normal functional parameters with no evidence of cardiac injury, hemopericardium, or congenital defect. All the pellets seen after radiological examination had corresponding entry wounds except for the pellet seen in the femoral area.
Figure 1: Coronal reconstruction of computed tomography thorax of the patient along with a line diagram showing bullet trajectory toward the right inferior pulmonary vein. (PV-Pulmonary vein)

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At surgery, an intraluminal pellet was found in the right superficial femoral artery. Arteriotomy was done and the pellet was retrieved [Figure 2]. Complete thrombectomy with both forward and backward bleed was achieved with Fogarty catheter after which distal circulation was established. An intercostal tube was passed on the right side and about 350 mL of blood drained slowly. As the patient was hemodynamically stable, thoracotomy was deferred and planned only in case of any deterioration. He was heparinized postoperatively. The patient's intercostal drainage gradually decreased and the intercostal tube was removed on the 5th postoperative day after repeat CT thorax and 2D-echocardiography. At 1 month follow-up, the patient was doing well.
Figure 2: Intraoperative picture showing femoral arteriotomy (A) and extracted pellet (B)

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   Discussion Top


ME is rare and was seen in 0.3% of 7500 cases of gunshot wounds during the Vietnam War; and 1.1% of 346 bullet injuries during the Afghanistan and Iraq wars.[4] Thomas Davis reported the first case of intravascular migration of a foreign body after a self-inflicted injury in 1834.[8]

To become an embolus, the missile should be of low-caliber and have just sufficient kinetic energy to come to rest in the lumen of the vessel; to be carried away in the blood stream to occlude a distant vessel.[9]

The clinical picture in a patient with ME is often confusing.[8],[10] It should be suspected in a patient with gunshot injury when:

  1. There is an entry wound without an exit wound
  2. The missile is seen to lie away from the anticipated trajectory
  3. A missile which is found to wander and lie in different positions during serial radiological investigations
  4. There is loss of peripheral arterial pulsations with ischemic sequelae
  5. A missile appears out of focus in the cardiac silhouette in a chest radiograph and
  6. The missile appears in the central portion of the lung (within the pulmonary artery).[10]


ME is classified into (a) arterial, (b) venous, and (c) paradoxical.[4],[5],[6],[7] Systemic arterial ME occurs from penetration of the left cardiac chambers, aorta, PVs or after paradoxical entry to left chambers of the heart through atrial septal defect, ventricular septal defect, or a patent foramen ovale.[11] Migration of arterial missile is then determined mainly by the force of blood flow, anatomy of branches of aorta and to some extent, gravity.[5],[12]

Systemic ME through the PV is extremely rare. Mattox et al.[10] reported a fairly large series of 28 cases of bullet embolism and also reviewed published reports of bullet embolism in 141 patients; and in none of them, the entry of the missile was through the PV. After the review of published literature till date, we have found only nine case reports [Table 1] wherein the missile entered the PV resulting in systemic embolization.[3],[8],[9],[13],[14],[15],[16],[17]
Table 1: Summary of all cases of systemic missile embolism through pulmonary vein

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Embolism through PV can be surmised when:

  • In the presence of systemic ME, there is absence of clinical or radiological evidence of injury to cardia or aorta and
  • There is no significant intra-thoracic bleeding requiring surgical intervention.


Bleeding from PV is minimal or self-limiting as they are low-pressure channels,[18] and the low-caliber low-velocity bullet causes minimal local tissue injury during penetration through the elastic and/or muscular wall of the vessel.[2] Thoracotomy is therefore rarely indicated.

The right inferior PV has an almost transverse course along the intersegmental septum till just before it enters the pericardium, where it is almost vertical, and it opens anteriorly and inferiorly into the left atrium.[19] The CT thorax of our patient [Figure 1] showed the trajectory of the pellet corresponding to the right inferior PV. The course of the pellet in our patient was probably: right inferior PV, to the left atrium, to the left ventricle, and to the systemic circulation until it got lodged in the right femoral artery. In our patient, 2D-echocardiography did not suggest any injury to the heart or its valves, hemopericardium, or any congenital defects. If the pellet had entered the right heart chambers, the embolism would have been into the pulmonary circulation.

Arterial embolization accounts for 80% of ME and presents early due to ischemic symptoms.[4],[20] Trimble's series showed that ME was three times more frequent in the lower limbs as compared to upper limbs. In [Table 1], of 10 cases, 3 had upper limb involvement and 4 had lower limb involvement. ME is also reported three times more commonly in the left lower limb as compared to the right.[2],[5],[21] This has been attributed to the less acute angle (30°) of aorta with left common iliac artery as compared to right common iliac artery (45°).[11],[21] However, in our review [Table 1], both the sides were equally involved (2 each). In upper limb, the right side is more commonly affected due to the large caliber of right brachiocephalic artery.[2] In our review [Table 1], the right upper limb was involved in three cases and right internal carotid artery (ICA) was involved in 3.

In addition to chest X-ray and CT of thorax, whole-body X-ray can help in locating the missing bullet.[10] Angiogram can further show the exact location of the bullet, aiding in surgical management.[2],[10] Shannon et al. in their series, state that X-ray screening documented 86% of ME and was supplemented by arteriographic studies in 36%.[2]

It is generally believed that patients with arterial ME are at high risk for ischemic complications.[4] Hence, removal of the missile is considered mandatory.[22] However, sometimes, delayed embolectomy may result from delayed or nonrecognition of the embolic event.[2] In our review [Table 1], seven embolic missiles were removed and three left in situ (one expired without investigations, one left in profunda femoris as the perfusion of the limb was good and the last left in right ICA. Endovascular intervention for retrieval is not advocated for intra-arterial bullet as it may be adherent to intima of the artery.[3]

In our case review, only one patient underwent thoracotomy for an associated lung laceration and the site of ME into pulmonary vein did not require surgical intervention in any of the cases. Apart from the earliest patient reported by Schmidt who did not undergo any surgical intervention, only one other patient died due to massive cerebral infarct. Two other patients with ICA embolus recovered with mild left hemiparesis. All the other patients had good outcome.


   Conclusion Top


  1. ME through PV is to be suspected when there is no evidence of cardiac or aortic injury clinically or radiologically in the presence of systemic arterial embolism
  2. If ME is suspected, all peripheral pulses have to be examined, and any evidence of peripheral ischemia should be noted. Whole-body X-ray supplemented with an arteriogram can localize the missile. CT scan of the thorax and 2Dechocardiogram are invaluable for complete assessment
  3. Minimum-to-moderate hemothorax or pneumothorax may be present. However, eanguinating bleed requiring thoracotomy is highly unusual
  4. Early detection of arterial ME can prevent ischemic damage and other delayed complications, ensuring good outcome.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Duke E, Peterson AA, Erly WK. Migrating bullet: A case of a bullet embolism to the pulmonary artery with secondary pulmonary infarction after gunshot wound to the left globe. J Emerg Trauma Shock 2014;7:38-40.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Shannon JJ Jr., Vo NM, Stanton PE Jr., Dimler M. Peripheral arterial missile embolization: A case report and 22-year literature review. J Vasc Surg 1987;5:773-8.  Back to cited text no. 2
    
3.
Ntlhe LM, Komati SM, Fourie PA, Rossouw AP. Missile embolism – Pulmonary vein to systemic bullet embolism: A case report and review of the literature. S Afr J Surg 2008;46:58, 60.  Back to cited text no. 3
    
4.
Nolan T, Phan H, Hardy AH, Khanna P, Dong P. Bullet embolization: Multidisciplinary approach by interventional radiology and surgery. Semin Intervent Radiol 2012;29:192-6.  Back to cited text no. 4
    
5.
Trimble C. Arterial bullet embolism following thoracic gunshot wounds. Ann Surg 1968;168:911-6.  Back to cited text no. 5
    
6.
Schurr M, McCord S, Croce M. Paradoxical bullet embolism: Case report and literature review. J Trauma 1996;40:1034-6.  Back to cited text no. 6
    
7.
Corbett H, Paulsen EK, Smith RS, Carman CG. Paradoxical bullet embolus from the vena cava: A case report. J Trauma 2003;55:979-81.  Back to cited text no. 7
    
8.
Klitenick M, Suarez C. Pulmonary vein to systemic artery missile embolus. J Trauma 1982;22:968-70.  Back to cited text no. 8
    
9.
Kerr A, Louie W. Bullet embolus from a pulmonary vein to the right axillary artery. Cardiovasc Intervent Radiol 1993;16:178-9.  Back to cited text no. 9
    
10.
Mattox KL, Beall AC Jr., Ennix CL, DeBakey ME. Intravascular migratory bullets. Am J Surg 1979;137:192-5.  Back to cited text no. 10
    
11.
Habdank K, Nolan RL. Gunshot wound to the thorax with bullet embolization to the external carotid artery. J Thorac Imaging 2003;18:42-4.  Back to cited text no. 11
    
12.
Symbas PN, Harlaftis N. Bullet emboli in the pulmonary and systemic arteries. Ann Surg 1977;185:318-20.  Back to cited text no. 12
    
13.
Burihan E, Pepe EV, Miranda F Jr. Bullet embolism following gunshot wound of the chest. Case report and review of the literature. J Cardiovasc Surg (Torino) 1980;21:711-6.  Back to cited text no. 13
    
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Rajamani K, Fisher M. Images in clinical medicine. Bullet embolism. N Engl J Med 1998;339:812.  Back to cited text no. 14
    
15.
Braun SD. Arterial embolization of a bullet. AJR Am J Roentgenol 2003;180:281.  Back to cited text no. 15
    
16.
Duncan IC, Fourie PA. Embolization of a bullet in the internal carotid artery. AJR Am J Roentgenol 2002;178:1572-3.  Back to cited text no. 16
    
17.
Ronsivalle J, Statler J, Venbrux AC, Arepally A. Intravascular bullet migration: A report of two cases. Mil Med 2005;170:1044-7.  Back to cited text no. 17
    
18.
Chaliki HP, Hurrell DG, Nishimura RA, Reinke RA, Appleton CP. Pulmonary venous pressure: Relationship to pulmonary artery, pulmonary wedge, and left atrial pressure in normal, lightly sedated dogs. Catheter Cardiovasc Interv 2002;56:432-8.  Back to cited text no. 18
    
19.
Knipe H. Pulmonary Veins. Available from: https://radiopaedia.org/articles/pulmonary-veins. [Last accessed on 2018 Oct 18].  Back to cited text no. 19
    
20.
Michelassi F, Pietrabissa A, Ferrari M, Mosca F, Vargish T, Moosa HH. Bullet emboli to the systemic and venous circulation. Surgery 1990;107:239-45.  Back to cited text no. 20
    
21.
Garzon A, Gliedman ML. Peripheral embolization of a bullet following perforation of the thoracic aorta. Ann Surg 1964;160:901-4.  Back to cited text no. 21
    
22.
Adegboyega PA, Sustento-Reodica N, Adesokan A. Arterial bullet embolism resulting in delayed vascular insufficiency: A rationale for mandatory extraction. J Trauma 1996;41:539-41.  Back to cited text no. 22
    

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Correspondence Address:
Dr. Radhikaraj C Govindaraju
Department of General Surgery, Goa Medical College, Bambolim - 403 202, Goa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_59_19

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