Asian Cardiovasc Thorac Ann 2007;15:154-156
© 2007 Asia Publishing EXchange Ltd
Wandering Bullet Embolizing to the Pulmonary Artery: A Case Report
Surendra K Agarwal, MCh,
Amrendra Singh, MS,
Manoj Kathuria, MD1,
Probal K Ghosh, MCh
Department of Cardiovascular and Thoracic Surgery
1 Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
For reprint information contact: Surendra K Agarwal MD Tel: 91 522 440 004-8 Ext 2208 Fax: 91 522 440 017 Email: amars546{at}rediffmail.com, Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226014 (UP), India.
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ABSTRACT
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Whilst a missile embolizing to the right side of the heart is a common occurrence, embolization to the pulmonary arteries is rare. We report a case of a bullet entering through the right internal jugular vein to the right ventricle, and then migrating to the left pulmonary artery, and its management. To our knowledge, this is the first reported such case from the Indian subcontinent.
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INTRODUCTION
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Bullets and pellets from gunshot injuries have been known to travel through the vascular system, however they rarely travel through the right heart to the pulmonary artery. The rising incidence of civilian trauma from low velocity gunshot wounds, particularly in urban areas, increases the likelihood of encountering bullet embolism. Our experience with bullet embolism to the pulmonary artery is presented along with a review of the literature.
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CASE REPORT
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A 20-year-old male patient sustained a gunshot injury to the right side of the neck due to assault. The patient was taken to a community hospital where he was found to be hemodynamically stable and neurological examination did not reveal any significant findings. He was given treatment for bleeding in the form of compression, and the bleeding stopped. A chest X-Ray (Figure 1
) performed showed a bullet in the heart and the patient was referred to our institution. On examination he was found to have a thrill in the neck. He also complained of chest pain. A digital substraction angiography (DSA) (Figure 2) showed a bullet in the inferior branch of the left pulmonary artery (LPA) in addition to revealing a right carotico-jugular fistula (Figure 3). Lateral neck X-Ray did not reveal any significant findings.
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Figure 2. Digital substraction angiogram showing the bullet in the left inferior pulmonary artery branch.
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The patient was referred for surgery. After left posterolateral thoracotomy, the inferior pulmonary artery was palpated through the lung. A proximal control on the LPA was taken and dissection was performed at the hilum. The bullet was extracted through an incision in the LPA that was subsequently repaired by direct sutures. The right common carotid artery and the internal jugular vein were dissected via a vertical incision in the right side of the neck and the carotico-jugular fistula was repaired through a venous approach. Postoperative course of the patient was uneventful and the patient was discharged on postoperative day 7. Follow-up chest X-Ray showed no abnormality in the lung fields and the pulmonary function test was normal.
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DISCUSSION
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The first report of a bullet embolus is attributed to Thomas Davis, who in 1834 reported a case of a 10-year-old boy with a wooden missile fragment that moved to his right ventricle.1 Pulmonary artery bullet embolism is rare, but may be managed in most cases without cardiopulmonary bypass. This is the first such case being reported from India.
Most bullets which enter the body gain access to the vascular system either through the venous system or through the heart. The bullets having low kinetic energy while passing through the soft tissue, lose some kinetic energy and thus may traverse only one wall of the vessel. High velocity missiles, as would be expected, are rarely the cause of vessel embolization. Occasionally the missile may create an arteriovenous fistula prior to embolization. Factors affecting the migration of bullets in the venous system include missile size, gravity, patient position, muscular and respiratory movement, and the force of venous blood flow. Hypotension at the time of injury may also play a role.4 Migrating venous bullets are more likely to lodge in the right ventricle than the pulmonary arterial tree since they tend to trap beneath the tricuspid valve or beneath the cordae tendineae.2,3 A missile entering the right heart may also embolize against the flow of blood and lodge in the inferior vena cava and its tributaries. Paradoxical embolization through a patent foramen ovale with subsequent lodging in peripheral arteries can occur. Emboli may shift from one pulmonary artery to the other with changes in patient position.1,2,5
A missile embolus should be suspected if no exit wound is found and the bullet is not found at the point of entry. The clinical picture of systemic artery bullet embolization may vary. Generally patients have features of ischemia, but clinical presentation ranges from an absence of symptoms as in our case, to massive lung infarction and death. Chest pain, dyspnea, cough and hemoptysis are the most common symptoms and are usually related to pulmonary vascular thrombosis, pulmonary infarction, erosion or sepsis.8
Diagnosis of pulmonary vascular missile is made by chest X-Ray and CT scan. Some controversy surrounds the management of embolized missiles in the pulmonary artery. Treatment options include thoracotomy and arteriotomy, thoracotomy and lobectomy, catheter extraction, and observation. It has been suggested that if the patient is asymptomatic, operative intervention to remove the bullet should not be done, since it is more hazardous to the patient than the retained missile. However, Stephenson et al4 and others7 strongly recommended the removal of all embolized bullets, and have reported a mortality rate of 80% in patients with retained intrapulmonary artery missiles. Massad and Slim6 also advocated early embolectomy because of dangers of sepsis, thrombus propagation, further embolization, or stenosis. Once embolectomy is decided upon, preoperative pulmonary angiography is mandatory to locate the missile. Petsas et al5 recommend using the Swan-Ganz (Edwards Lifesciences Corporation, Irvine, CA) balloon catheter for arteriography; the catheter can be advanced into the involved artery and the balloon inflated to prevent migration of the bullet during operative manipulation. In the case presenting with pulmonary infarction, ligation of the artery and lobectomy should be performed.
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REFERENCES
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- Mattox KL, Beall AC Jr, Ennix CL, DeBakey ME. Intravascular migratory bullets. Am J Surg 1979;137:192–5.[Medline]
- Barrett NR. Foreign bodies in the cardiovascular system. Br J Surg 1950;37:416–45.[Medline]
- Ledgerwood AM. The wandering bullet. Surg Clin No Am 1981;57:97–109.
- Stephenson LW, Workman RB, Aldrete JS, Karp RB. Bullet emboli to the pulmonary artery: a report of 2 patients and review of the literature. Ann Thorac Surg 1976;21:333–6.[Abstract]
- Petsas AA, Ghahramani AR, Green R. A wandering bullet. Successful removal and a simple technique to prevent its migration. J Thorac Cardiovasc Surg 1975;69:954–6.[Abstract]
- Massad M, Slim MS. Intravascular missile embolization in childhood: report of a case, literature review, and recommendations for management. J Pediatr Surg 1990;25:1292–4.[Medline]
- Ezberci F, Kargi H. Surgical management of a pulmonary artery missile embolism after an air rifle wound to the liver. South Med J 1999;92:1207–9.[Medline]
- Actis Dato GM, Arslanian A, Di Marizo P, Filosso PL, Ruffini E. Posttraumatic and iatrogenic foreign bodies in the heart: report of fourteen cases and review of the literature. J Thorac Cardiovasc Surg 2003;126:408–14.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
