Venous bullet embolism to the right ventricle
H J S Bining, MD, FRCP(C) 1 G P Artho, MD, FMH 1 P D Vuong, BS, MD 1 D C Evans, MD, FRCSC, FACS 2 and T Powell, MD, FFR(RCSI) 1
1 Department of Diagnostic Radiology, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, 2 Trauma Services, Vancouver General Hospital, 855W 12th Avenue, Vancouver, BC V5Z 1M9, Canada
Correspondence: DrBining, Radiology Resident, Department of Diagnostic Radiology, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada. E-mail: firstname.lastname@example.org
| Abstract |
Bullet embolism is a rare complication of penetrating vascular trauma that requires a high index of suspicion for timely diagnosis and management.Delays in identification may result in poor early management and subsequent loss of limb or life . There are two types of bullet embolism: arterial and venous. In this report, we discuss a rare case of venous bullet embolus to the right ventricle from the right femoral vein.
| Case report |
A 30-year-old manpresented to our trauma unit following an altercation. He was haemodynamically stable with gunshot wounds to the right groin, left thigh and left flank/buttock regions. Normal pulses were palpated with no evidence of impaired perfusion to the lower limbs. Abdominal examination was unremarkable, with no evidence of wounds to the chest or upper abdomen. ECG demonstrated a normal sinus rhythm with nocardiac arrhythmias.
Because the patient was stable, a CT of the abdomen was performed to evaluate the pelvis and retroperitoneum, and to elucidate the bullet trajectories. The scout films from the CT abdomen demonstrated a metallic density in the region of the right ventricle (Figure 1a,b). The subsequent CT demonstrated a bullet fragment within the right ventricle (Figure 1c). No intraabdominal,intrathoracic or retroperitoneal injury was identified. In addition, no bullet wound sites were noted in the chest or upper abdomen. The CT demonstrated the entry site in the region of the right femoral vessels with associated subcutaneous emphysema and several metallic pieces (Figure 1d). Transthoracic echocardiography demonstrated a hyperechoic structure adjacent to the free wall of the rightventricle. There was no associated pericardial effusion or evidence of free wall perforation. Based on these findings, venous bullet embolus was suspected from the right femoral vein to the right ventricle.
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| Figure 1. A 30-year-old man with gunshot wounds to the pelvic region. Anteroposterior (a) and lateral (b) CTscout films demonstrate a metallic foreign body (bullet fragment) projecting in the right ventricular region. In addition, small calcifications in both hilar regions were noted, which were confirmed on CT. (c) CT image of the heart shows a retained bullet fragment within the right ventricle. (d) CT image at the level of the groin shows subcutaneous emphysema and a metallic bullet fragment adjacent tothe right femoral vessels. |
No attempt was made to retrieve the bullet via fluoroscopy-guided percutaneous transvenous approach, as has been advocated by some authors . Lack of experience with percutaneous retrieval resulted in the trauma team's decision for surgical approach. The patient was taken to the operating room where he underwent a transoesophageal echocardiography to confirmthe bullet's location. Using cardiopulmonary bypass, a median sternotomy with right atriotomy was performed. The bullet was identified through the tricuspid valve and found to be embedded in the trabeculated right ventricular wall underneath the tricuspid valve. The bullet was removed successfully. There was no right ventricular wall penetration and no damage to adjacent structures including the...
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