Intravascular Migratory Bullets Kenneth L. Mattox, MD, Houston, Texas Arthur C. Beall, Jr, MD, Houston, Coyness L. Ennix, MD, Houston,
Texas Texas
Michael E. DeBakey, MD, Houston,
Texas
Foreign bodies have entered the cardiovascular system and embolized in various directions, causing confusion on the part of the examining physician. Infection and ischemia in organs and tissues quite distant from the site of injury may be the result of intravascular emboli, and in some patients amputation or death may result. A great variety of objects have been described to embolize, among them pins, needles, and bits of wood [I]. Bullets, pellets, and fragments of bullets have been reported to migrate from the peripheral veins to the heart and pulmonary arteries and retrograde down the inferior vena cava against the flow of blood [1,2]. Arterial emboli have likewise been described [I]. Most reports are single case histories. The present report deals with a relatively large series of patients seen in one institution with intravascular bullets in venous, arterial, pulmonary, and cardiac locations. Clinical Material
Between January 1965 and December 1977, twenty-eight were seen at the Ben Taub General Hospital in Houston with intravascular bullet emboli. There were twenty-one males and seven females, ranging in age from seventeen to fifty-two years. Three of these cases have previously been reported [3]. Seven patients had injury patients
from missiles ranging from pellets to a 0.32 caliber bullet which entered the peripheral veins and lodged in the pulmonary artery. (Table I.) Two of these missiles were removed, with the small fragments and pellets being left in place. (Table II.) Six patients had missile entrance in the abdominal aorta and subsequent embolization to peripheral arteries. Five had entry in the peripheral venous system with embolization to the heart, while four had entry in the thoracic aorta with peripheral embolization, and two patients had missiles entering the right heart with embolization into the inferior vena cava. One missile entered From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine. and the Ben Taub General Hosoital. Houston. Texas. Reprint requests should be addressed‘to_Kenneth L. M&ox. MD, 1200 Moursund Avenue, Houston, Texas 77030. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
192
the inferior vena cava and eventually lodged in the distal abdominal aorta after having traversed the atria1 septum, either by its energy or as a paradoxic embolus. (Table I.) The final destination of intravascular missiles included the pulmonary arteries, heart, femoral artery, popliteal artery, and iliac arteries. (Table I.) Twenty of twenty-eight missiles were successfully removed. Seven of the missiles were left in place because of their small size or because the patient left against medical advice. (Table II.) Associated enteric injuries which might have produced contamination of the missiles before entering the cardiovascular system involved the lung (7 patients), colon (4), small bowel (3), diaphragm (3), liver (3), stomach (2), spleen (l), and kidney (1). All five missiles removed from the heart were removed under cardiopulmonary bypass. X-ray films were taken just prior to institution of cardiopulmonary bypass and again just prior to clamping of the pulmonary artery to assure that the bullet was still in the right ventricle. Furthermore, after lateral decubitis positioning of the patients who had embolization to the pulmonary artery, x-ray films were taken to assure that the bullet had not dropped to the opposite pulmonary artery. Results
Removal of intravascular bullet emboli was successful in twenty of twenty-one patients; in one patient a missile which entered the heart and embolized to the carotid artery at the base of the skull could not be removed, and despite ligation of the internal carotid artery, the patient died of intracerebral edema. At autopsy there was propagation of clot beyond the carotid syphon with acute infarction of the brain without hemorrhage. Five pellets and bullet fragments left in the pulmonary artery caused no longterm sequelae, and these patients were asymptomatic when last seen in follow-up. The two patients with retrograde emboli, in one to the hepatic vein and in one to the renal vein, were lost to follow-up since they left the hospital against medical advice. Among the twenty-eight patients there were two deaths. One patient died from cerebral infarction after a missile embolus had lodged in the carotid ar-
The American Journal of Surgery
Intravascular
TABLE I
Origin and Destination of Intravascular Bullet Emboli Source
Number
Peripheral venous to pulmonary artery Abdominal aorta to peripheral artery’ Peripheral venous artery to heart Thoracic aorta to peripheral artery* Heart to peripheral artery* Heart to inferior vena cavat Inferior vena cava to right atrium to left atrium to abdominal aorta
7 6 5 4 3 2
Total
1 28
* Aorta 1, iliac artery 3, femoral artery 4, popliteal artery 4, carotid artery 1. t To hepatic vein and renal vein.
tery. A second patient died of multiple associated injuries when a missile embolus lodged at the aortic bifurcation after having traversed the atria1 septum from the inferior vena cava. Of the remaining patients, two were lost to follow-up, and among the twenty-four patients available for follow-up, complications were minor, including atelectasis (4 patients), wound infection (3), psychosis (2), postpericardiotomy syndrome (2), pulmonary embolus (l), and thrombophlebitis (1). Comments Excluding the twenty-eight cases herein reported, 113 cases of intravascular migratory bullets have been reported [1,4-121. Since the first reported embolus by Davis [13] in 1834, considerable controversy has arisen concerning whether or not to remove missiles, when to remove them, various technics of removal, and reasons for migration. These debates may be moot in the present climate of an advanced understanding of trauma surgery and vascular surgical technics. Intravascular migratory bullets may penetrate a vascular or cardiac lumen by direct energy propulsion or may later erode into the vessel [14]. Penetration of the cardiovascular system after the ingestion of foreign bodies has been reported [I]. Intravascular migration of a missile may be delayed up to fourteen years [1,6], or it may occur soon after injury. It is extremely important to localize the missile preoperatively by x-ray, since reembolization of the missile may continue to occur [ 71. The missiles may embolize secondary to positional changes combined with the weight of the bullet and gravity, moving from the heart to the pulmonary artery, from one pulmonary artery to the opposite pulmonary artery, or even down the inferior vena cava [6,15-181. It has been postulated that the direction of embolization
Volume 137, February 1979
TABLE II
Migratory Bullets
Treatment for Bullet Emboli Number
Removal Peripheral artery Heart Pulmonary artery Aortic bifurcation Attempted Removal Unsuccessful (carotid) Left in Place Pulmonary artery Hepatic vein Renal vein Total
12 5 2 1 1 5 1 1 28
may be related to the patient’s position immediately after wounding [17]. Following isolation of embolized missiles, operative removal is, in general, recommended. The technical aspects of such removal have been described [3,5,19]. The inexperienced trauma surgeon may assume that bullets travel in a straight line from the point of entrance to exit or to the final resting place; however, those with more experience realize that bullets take various circuitous routes, depending upon the patient’s position and the ability of a bullet to ricochet off various structures and organs. The patient with an intravascular migratory bullet presents a confusing picture. The signs and symptoms do not correlate with those expected from the suspected course of the missile. Additional clues that a missile embolus has occurred include loss of peripheral pulses, a missile out of focus appearing within the cardiac silhouette, and a missile appearing within the central portion of the lung (within the pulmonary artery). Delayed symptoms may include pain, gangrene, claudication, peripheral vascular insufficiency, pericardial effusion, pleural effusion, cardiac arrhythmias, endocarditis, sepsis, pseudoaneurysm formation, and neurosis or even frank psychosis. Bullet emboli to the heart have occurred mainly from the right side and have included missiles entering the head, femoral vein, iliac veins, and inferior vena cava. (Table III.) Bland and Beebe [20] in 1919 reported a case in which a bullet to the pulmonary vein embolized to the left ventricle. In recent years, bullet emboli to the heart have been removed by cardiopulmonary bypass [3,21,22], although one case of removal with a wire basket has been reported in a medical newspaper (Hospital Tribune, May 5,1975). Reasons for removing a bullet embolus to the heart include prevention of bacterial endocarditis, recurrent pericardial effusion, and myocardiac irritability, in addition to prevention of interference with the
193
Mattox et al
TABLE III
Reported Bullet Emboll (including those reported herein) source
Destination
Venous Venous Venous Venous Heart Thoracic aorta Unknown thoracic Abdominal aorta Peripheral arterial
Heart Pulmonary artery Retrograde venous ParadoxicIarterial Arterial Arterial Arterial Arterial Arterial
References 1,3,6,13,21,22 1,5,7,6,16,20,21,23,26,27,26 12.5 1,12,24,34 1,10,11,25,29,30 1,10,11,31,32,33 9,10,11 5.12.19 139
valvular mechanism of the tricuspid valve and anxiety neuroses [3,21,25,35,36]. Emboli arising from peripheral veins, the inferior vena cava, and even the right heart have been reported to lodge in the pulmonary arteries. (Table III.) Debate exists as to whether or not a missile in the pulmonary artery should be removed [5,7,8,37,38]. In a review of the literature by Symbas and Harlaftis [ 71, the patients not undergoing bullet embolectomy had a higher mortality, and it was recommended that all missile emboli to the lung be removed. However, in the present report and in other series, small emboli have been left in place without untoward sequelae. Saylam, Bozer, and Kadioglu [28] recommended segmentectomy or lobe&my in individuals who have had delayed discovery of a bullet embolus to the lung. Patients with emboli to a main or secondary pulmonary artery should have localization determined using intraoperative x-ray [6,15-181. Reembolization to the opposite pulmonary artery has been reported by Bland and Beebe [20], Petsas, Ghahramani, and Green [16] and Barrett [I]. In cases of intrathoracic embolization requiring intraabdominal and intrathoracic incisions, two separate incisions are recommended to prevent enteric contamination of the pleural or pericardial space from the penetrating abdominal injury [3,38]. Penetration of the thorax may result in an injury to the heart, thoracic aorta, or unknown penetration sites with distal embolization. (Table III.) Although exsanguinating hemorrhage, pericardial tamponade, and uncontrolled hemothorax do not always occur, a high mortality has resulted from lack of control of the vascular entrance site. Missiles have embolized to the bifurcation of the aorta as well as to the poplit&, posterior tibial, and axillary arteries. Although amputation is not always a sequela when emboli are not removed, among those patients who survived there was a significant amputation rate due to either delayed removal or nonremoval of the bullet emboli [IO]. It is recommended at the present time that the site of entrance be controlled first and that removal of the peripheral emboli be performed simulta194
Number
Mortality
34 30 7 5 19 15 15 13 3
26 % 30% 0 4% 21% 47% 20% 70% 33%
neously if the patient’s status allows. It is further recommended that after removal of the missile and prior to lateral arteriorrhaphy, a Fogarty catheter be utilized for thrombectomy [16,19]. Missiles may enter the abdominal aorta with more distal embolization to as far as the popliteal arteries. (Table III.) Among the thirteen patients in the literature (excluding those reported on herein) in whom there was penetration of the abdominal aorta with peripheral embolization, nine died. One survivor in whom the wound entrance was at the abdominal aorta near ‘the celiac axis underwent cardiopulmonary bypass for perfusion of the kidneys during the time of suprarenal aortic clamping and repair of the entrance site [38]. Missiles may,enter a peripheral artery and may embolize even more peripherally. (Table III.) Of three such patients in the literature, one died of embolization from the carotid artery to the middle cerebral artery and in another coma and subsequent right hemiplegia from a similar embolization of a small missile developed. The third patient lived
PI. Missiles may enter the right-sided circulation with paradoxical embolization through a patent foramen of Ovale and lodge in peripheral arteries. In our case, momentum of the missile apparently caused penetration of the atria1 septum. One of the early cases of paradoxical bullet emboli was reported in 1917 by Specht [39,40]. This patient had embolization from the femoral vein to the right atrium across a widely patent foramen of Ovale, and the bullet lodged beneath the mitral valve. He later died. Five cases of paradoxical bullet embolus have been reported. (Table III.) The missile may enter the right heart or upper extremity veins, finding its way to the right atrium, embolizing against the flow of blood, and lodging in the inferior vena cava or in veins supplying the inferior vena cava. (Table III.) It is postulated that such retrograde embolization occurs because of the patient’s position, the weight and shape of the missile, possible low flow states, and hypotension at the time The American Journal of Surgery
Intravascular
of wounding. With the two cases in this report, a total of six cases of retrograde embolization appears in the literature. Migratory intravascular bullets produce a confusing picture to the physician evaluating the trauma patient. Local, systemic, and distant complications may occur. Diagnostic procedures to assist in ferreting out the accurate clinical picture include arteriography, venography, and physical examination, although many of the cases are diagnosed serendipitously at the time of exploratory surgery. With advances in the surgical art, most bullet emboli should be removed using one of a variety of technics with control of the entrance site as soon as the embolization is discovered. Prior to the final incision for removal of the migratory bullet, there should be specific relocalization of the bullet to prevent an unnecessary and ill planned incision.
Summary
The estimated course of a penetrating missile provides some clues to planning intraoperative priorities and management. However, missiles which become intravascular emboli present diagnostic and therapeutic dilemmas. Twenty-eight patients have been seen with bullet emboli. Five patients had emboli to the lungs, two of which were removed. Two large bullets embolized from a right heart injury down the inferior vena cava, one to a hepatic vein and one to the right renal vein. Fourteen patients had arterial bullet emboli, four originating in the heart, four in the thoracic aorta, and six in the abdominal aorta. Two patients died, one of cerebral infarction secondary to bullet embolus to the right carotid artery and one of an unrecognized traumatic intracardiac defect. Complications were secondary to associated injuries rather than a result of removal of bullet emboli.
References 1. Barrett NR: Foreign bodies in the cardiovascular system. 6r J Surg 37: 416, 1960. 2. Frazier TG, Belcastro VJ, lnouye WY: Trans-thoracic venous bullet embolism. J Trauma 15: 625, 1975. 3. Morton JR, Reul GL, Arbegast NR, et al: Bullet embolus to the right ventricle. Am J Surg 122: 564, 1971. 4. Kelly JL: A bullet embolism to the left femoral artery following a thoracic gunshot wound. J Thorac Cardiovasc Surg 21: 606, 1951. 5. Ledgerwood AM: The wandering bullet. Surg C/in Norfh Am 57(l): 97, 1977. 6. Padula FIT, Sandler SC, Camishion RC: Delayed bullet embolization to the heart following abdominal gunshot wound. Ann Surg 169: 599. 1969. 7. Symbas PN, Harlaftis N: Bullet emboli in the pulmonary systemic arteries. Ann Surg 165: 318, 1977.
Volume 137, February 1979
Migratory
Bullets
8. Symbas PN, Hatcher CR, Mansour KA: Projectile embolus of the lung. J Thorac Cardiovasc Surg 56: 97, 1968. 9. Taylor MT. Schlegel DM, Habeggar i%: Bullet embolism. Am J Surg 114: 457, 1967. 10. Trimble C: Arterial bullet embolism following thoracic gunshot wounds, Ann Surg 168: 911, 1968. 11. Ward PA, Suzuki A: Gunshot wound of the heart with peripheral embolization. J Thorac Cardiovasc Surg 68: 440, 1974. 12. Yajko RD, Trimble C: Arterial bullet embolism following abdominal gunshot wounds. J Trauma 14: 200. 1974. 13. Davis TD: Cited in [ I]. 14. Momm M: Ein schuss durch Lever und Aorta, tod Nach vier Wochen infolge Sepsis. Dtsch A&d Wochenschr 36: 2422, 1910. 15. Schloffer H: Bullet embolization and remarks concerning bullet injuries of the heart and great vessels. 6eitr K/in Chir 37: 698, 1903. 16. Petsas AA, Ghahramani AR, Green R: A wandering bullet. J Thorac Cardiovasc Sura 69: 954. 1975. 17. Straus R: Pulmonary embo&n caused by a lead bullet fotlowing gunshot wound of the abdomen. Arch Pathol 33: 63, 1942. 18. Borzekey R, Ueberstich WD: Schussverlatzungen des Thorax. Beitr K/in Chir 40: 243, 1903. 19. Painter W, Britt LG: Distal bullet embolism after gunshot wound of the chest. Am Surg 37: 106, 1971. 20. Bland EF, Beebe GW: Missiles in the heart. N Engl J Med 274: 1039, 1966. 21. Bartlett H, Anderson CV, Steinhoff NG: Bullet embolism to the heart. J Trauma 13: 476, 1973. 22. Hiebert CA, Gregory FJ: Bullet embolism from the head to the heart. JAMA 229: 442, 1974. 23. Moore HG, Nyhus LM, Kanar EA. et al: Gunshot wounds of major arteries. Surg Gynecol Obstet 98: 129, 1954. 24. Neerken AJ, Clement FL: Air rifle wound of the heart with embolization. JAMA 189: 579, 1964. 25. Lewis RJ, Kunderman PJ: Bullet embolus of the heart. Chest 62: 627, 1972. 26. Paltouf R: Geschossembolie der Arteria pulmonalis. Wein K/in Wochenschr 46: 602, 1933. 27. Stephenson LW, Workman RB, Aldrete JS, et al: Bullet emboli to the pulmonary artery. Ann Thorac Surg 21: 333, 1976. 28. Saylam A. Bozer AY, Kadioglu Y: Migration of a bullet from the inferior vena cava to the right pulmonary artery. Jpn Heart J 13: 572, 1972. 29. Rodriquez MA, Rodger MR: Right axillary artery bullet embolus following gunshot wound of the back. J Trauma 15: 170, 1975. 30. Saltzstein EC, Freeark RJ: Bullet embolism to the right axillaty artery following gunshot wound of the heart. Ann Surg 158: 65, 1963. 31. Wilder J: Incredible journey. Time 108: 42, 1976. 32. Dillard BM, Staple TW: Bullet embolism from the aortic arch to the popliteal artery. Arch Surg 96: 326, 1969. 33. Garzon A, Gliedman ML: Peripheral embolization of a bullet following perforation of the thoracic aorta. Ann Surg 160: 901, 1964. 34. Lam CR, McIntyre R: Air pistol injury of pulmonary artery and aorta. J Thorac Cardlovasc Surg 59: 729, 1970. 35. tiarken DE, Williams AC: Foreign bodies within the blood vascular system. Am J Surg 72: 80, 1946. 36. Harken DE: Foreign bodies in and in relation to the thoracic blood vessels and heart. I. Techniques for approaching and removing foreign bodies from the chambers of the heart. Surg Gynecol Obstet 83: 117, 1946. 37. Samson PC: Two unusual cases of war wounds of the heart. Surgery 20: 373, 1946. 38. Mattox KL, Espada R, Beall AC Jr, Jordan GL Jr: Thoracotomy in the emergency center. J Am Co// Emerg Phys 3: 13, 1974. 39. Specht: Cited in [ I]. 40. Migration of projectiles in the blood stream (editorial). Lance1 2: 395. 1917.
195
Texas Texas
Michael E. DeBakey, MD, Houston,
Texas
Foreign bodies have entered the cardiovascular system and embolized in various directions, causing confusion on the part of the examining physician. Infection and ischemia in organs and tissues quite distant from the site of injury may be the result of intravascular emboli, and in some patients amputation or death may result. A great variety of objects have been described to embolize, among them pins, needles, and bits of wood [I]. Bullets, pellets, and fragments of bullets have been reported to migrate from the peripheral veins to the heart and pulmonary arteries and retrograde down the inferior vena cava against the flow of blood [1,2]. Arterial emboli have likewise been described [I]. Most reports are single case histories. The present report deals with a relatively large series of patients seen in one institution with intravascular bullets in venous, arterial, pulmonary, and cardiac locations. Clinical Material
Between January 1965 and December 1977, twenty-eight were seen at the Ben Taub General Hospital in Houston with intravascular bullet emboli. There were twenty-one males and seven females, ranging in age from seventeen to fifty-two years. Three of these cases have previously been reported [3]. Seven patients had injury patients
from missiles ranging from pellets to a 0.32 caliber bullet which entered the peripheral veins and lodged in the pulmonary artery. (Table I.) Two of these missiles were removed, with the small fragments and pellets being left in place. (Table II.) Six patients had missile entrance in the abdominal aorta and subsequent embolization to peripheral arteries. Five had entry in the peripheral venous system with embolization to the heart, while four had entry in the thoracic aorta with peripheral embolization, and two patients had missiles entering the right heart with embolization into the inferior vena cava. One missile entered From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine. and the Ben Taub General Hosoital. Houston. Texas. Reprint requests should be addressed‘to_Kenneth L. M&ox. MD, 1200 Moursund Avenue, Houston, Texas 77030. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
192
the inferior vena cava and eventually lodged in the distal abdominal aorta after having traversed the atria1 septum, either by its energy or as a paradoxic embolus. (Table I.) The final destination of intravascular missiles included the pulmonary arteries, heart, femoral artery, popliteal artery, and iliac arteries. (Table I.) Twenty of twenty-eight missiles were successfully removed. Seven of the missiles were left in place because of their small size or because the patient left against medical advice. (Table II.) Associated enteric injuries which might have produced contamination of the missiles before entering the cardiovascular system involved the lung (7 patients), colon (4), small bowel (3), diaphragm (3), liver (3), stomach (2), spleen (l), and kidney (1). All five missiles removed from the heart were removed under cardiopulmonary bypass. X-ray films were taken just prior to institution of cardiopulmonary bypass and again just prior to clamping of the pulmonary artery to assure that the bullet was still in the right ventricle. Furthermore, after lateral decubitis positioning of the patients who had embolization to the pulmonary artery, x-ray films were taken to assure that the bullet had not dropped to the opposite pulmonary artery. Results
Removal of intravascular bullet emboli was successful in twenty of twenty-one patients; in one patient a missile which entered the heart and embolized to the carotid artery at the base of the skull could not be removed, and despite ligation of the internal carotid artery, the patient died of intracerebral edema. At autopsy there was propagation of clot beyond the carotid syphon with acute infarction of the brain without hemorrhage. Five pellets and bullet fragments left in the pulmonary artery caused no longterm sequelae, and these patients were asymptomatic when last seen in follow-up. The two patients with retrograde emboli, in one to the hepatic vein and in one to the renal vein, were lost to follow-up since they left the hospital against medical advice. Among the twenty-eight patients there were two deaths. One patient died from cerebral infarction after a missile embolus had lodged in the carotid ar-
The American Journal of Surgery
Intravascular
TABLE I
Origin and Destination of Intravascular Bullet Emboli Source
Number
Peripheral venous to pulmonary artery Abdominal aorta to peripheral artery’ Peripheral venous artery to heart Thoracic aorta to peripheral artery* Heart to peripheral artery* Heart to inferior vena cavat Inferior vena cava to right atrium to left atrium to abdominal aorta
7 6 5 4 3 2
Total
1 28
* Aorta 1, iliac artery 3, femoral artery 4, popliteal artery 4, carotid artery 1. t To hepatic vein and renal vein.
tery. A second patient died of multiple associated injuries when a missile embolus lodged at the aortic bifurcation after having traversed the atria1 septum from the inferior vena cava. Of the remaining patients, two were lost to follow-up, and among the twenty-four patients available for follow-up, complications were minor, including atelectasis (4 patients), wound infection (3), psychosis (2), postpericardiotomy syndrome (2), pulmonary embolus (l), and thrombophlebitis (1). Comments Excluding the twenty-eight cases herein reported, 113 cases of intravascular migratory bullets have been reported [1,4-121. Since the first reported embolus by Davis [13] in 1834, considerable controversy has arisen concerning whether or not to remove missiles, when to remove them, various technics of removal, and reasons for migration. These debates may be moot in the present climate of an advanced understanding of trauma surgery and vascular surgical technics. Intravascular migratory bullets may penetrate a vascular or cardiac lumen by direct energy propulsion or may later erode into the vessel [14]. Penetration of the cardiovascular system after the ingestion of foreign bodies has been reported [I]. Intravascular migration of a missile may be delayed up to fourteen years [1,6], or it may occur soon after injury. It is extremely important to localize the missile preoperatively by x-ray, since reembolization of the missile may continue to occur [ 71. The missiles may embolize secondary to positional changes combined with the weight of the bullet and gravity, moving from the heart to the pulmonary artery, from one pulmonary artery to the opposite pulmonary artery, or even down the inferior vena cava [6,15-181. It has been postulated that the direction of embolization
Volume 137, February 1979
TABLE II
Migratory Bullets
Treatment for Bullet Emboli Number
Removal Peripheral artery Heart Pulmonary artery Aortic bifurcation Attempted Removal Unsuccessful (carotid) Left in Place Pulmonary artery Hepatic vein Renal vein Total
12 5 2 1 1 5 1 1 28
may be related to the patient’s position immediately after wounding [17]. Following isolation of embolized missiles, operative removal is, in general, recommended. The technical aspects of such removal have been described [3,5,19]. The inexperienced trauma surgeon may assume that bullets travel in a straight line from the point of entrance to exit or to the final resting place; however, those with more experience realize that bullets take various circuitous routes, depending upon the patient’s position and the ability of a bullet to ricochet off various structures and organs. The patient with an intravascular migratory bullet presents a confusing picture. The signs and symptoms do not correlate with those expected from the suspected course of the missile. Additional clues that a missile embolus has occurred include loss of peripheral pulses, a missile out of focus appearing within the cardiac silhouette, and a missile appearing within the central portion of the lung (within the pulmonary artery). Delayed symptoms may include pain, gangrene, claudication, peripheral vascular insufficiency, pericardial effusion, pleural effusion, cardiac arrhythmias, endocarditis, sepsis, pseudoaneurysm formation, and neurosis or even frank psychosis. Bullet emboli to the heart have occurred mainly from the right side and have included missiles entering the head, femoral vein, iliac veins, and inferior vena cava. (Table III.) Bland and Beebe [20] in 1919 reported a case in which a bullet to the pulmonary vein embolized to the left ventricle. In recent years, bullet emboli to the heart have been removed by cardiopulmonary bypass [3,21,22], although one case of removal with a wire basket has been reported in a medical newspaper (Hospital Tribune, May 5,1975). Reasons for removing a bullet embolus to the heart include prevention of bacterial endocarditis, recurrent pericardial effusion, and myocardiac irritability, in addition to prevention of interference with the
193
Mattox et al
TABLE III
Reported Bullet Emboll (including those reported herein) source
Destination
Venous Venous Venous Venous Heart Thoracic aorta Unknown thoracic Abdominal aorta Peripheral arterial
Heart Pulmonary artery Retrograde venous ParadoxicIarterial Arterial Arterial Arterial Arterial Arterial
References 1,3,6,13,21,22 1,5,7,6,16,20,21,23,26,27,26 12.5 1,12,24,34 1,10,11,25,29,30 1,10,11,31,32,33 9,10,11 5.12.19 139
valvular mechanism of the tricuspid valve and anxiety neuroses [3,21,25,35,36]. Emboli arising from peripheral veins, the inferior vena cava, and even the right heart have been reported to lodge in the pulmonary arteries. (Table III.) Debate exists as to whether or not a missile in the pulmonary artery should be removed [5,7,8,37,38]. In a review of the literature by Symbas and Harlaftis [ 71, the patients not undergoing bullet embolectomy had a higher mortality, and it was recommended that all missile emboli to the lung be removed. However, in the present report and in other series, small emboli have been left in place without untoward sequelae. Saylam, Bozer, and Kadioglu [28] recommended segmentectomy or lobe&my in individuals who have had delayed discovery of a bullet embolus to the lung. Patients with emboli to a main or secondary pulmonary artery should have localization determined using intraoperative x-ray [6,15-181. Reembolization to the opposite pulmonary artery has been reported by Bland and Beebe [20], Petsas, Ghahramani, and Green [16] and Barrett [I]. In cases of intrathoracic embolization requiring intraabdominal and intrathoracic incisions, two separate incisions are recommended to prevent enteric contamination of the pleural or pericardial space from the penetrating abdominal injury [3,38]. Penetration of the thorax may result in an injury to the heart, thoracic aorta, or unknown penetration sites with distal embolization. (Table III.) Although exsanguinating hemorrhage, pericardial tamponade, and uncontrolled hemothorax do not always occur, a high mortality has resulted from lack of control of the vascular entrance site. Missiles have embolized to the bifurcation of the aorta as well as to the poplit&, posterior tibial, and axillary arteries. Although amputation is not always a sequela when emboli are not removed, among those patients who survived there was a significant amputation rate due to either delayed removal or nonremoval of the bullet emboli [IO]. It is recommended at the present time that the site of entrance be controlled first and that removal of the peripheral emboli be performed simulta194
Number
Mortality
34 30 7 5 19 15 15 13 3
26 % 30% 0 4% 21% 47% 20% 70% 33%
neously if the patient’s status allows. It is further recommended that after removal of the missile and prior to lateral arteriorrhaphy, a Fogarty catheter be utilized for thrombectomy [16,19]. Missiles may enter the abdominal aorta with more distal embolization to as far as the popliteal arteries. (Table III.) Among the thirteen patients in the literature (excluding those reported on herein) in whom there was penetration of the abdominal aorta with peripheral embolization, nine died. One survivor in whom the wound entrance was at the abdominal aorta near ‘the celiac axis underwent cardiopulmonary bypass for perfusion of the kidneys during the time of suprarenal aortic clamping and repair of the entrance site [38]. Missiles may,enter a peripheral artery and may embolize even more peripherally. (Table III.) Of three such patients in the literature, one died of embolization from the carotid artery to the middle cerebral artery and in another coma and subsequent right hemiplegia from a similar embolization of a small missile developed. The third patient lived
PI. Missiles may enter the right-sided circulation with paradoxical embolization through a patent foramen of Ovale and lodge in peripheral arteries. In our case, momentum of the missile apparently caused penetration of the atria1 septum. One of the early cases of paradoxical bullet emboli was reported in 1917 by Specht [39,40]. This patient had embolization from the femoral vein to the right atrium across a widely patent foramen of Ovale, and the bullet lodged beneath the mitral valve. He later died. Five cases of paradoxical bullet embolus have been reported. (Table III.) The missile may enter the right heart or upper extremity veins, finding its way to the right atrium, embolizing against the flow of blood, and lodging in the inferior vena cava or in veins supplying the inferior vena cava. (Table III.) It is postulated that such retrograde embolization occurs because of the patient’s position, the weight and shape of the missile, possible low flow states, and hypotension at the time The American Journal of Surgery
Intravascular
of wounding. With the two cases in this report, a total of six cases of retrograde embolization appears in the literature. Migratory intravascular bullets produce a confusing picture to the physician evaluating the trauma patient. Local, systemic, and distant complications may occur. Diagnostic procedures to assist in ferreting out the accurate clinical picture include arteriography, venography, and physical examination, although many of the cases are diagnosed serendipitously at the time of exploratory surgery. With advances in the surgical art, most bullet emboli should be removed using one of a variety of technics with control of the entrance site as soon as the embolization is discovered. Prior to the final incision for removal of the migratory bullet, there should be specific relocalization of the bullet to prevent an unnecessary and ill planned incision.
Summary
The estimated course of a penetrating missile provides some clues to planning intraoperative priorities and management. However, missiles which become intravascular emboli present diagnostic and therapeutic dilemmas. Twenty-eight patients have been seen with bullet emboli. Five patients had emboli to the lungs, two of which were removed. Two large bullets embolized from a right heart injury down the inferior vena cava, one to a hepatic vein and one to the right renal vein. Fourteen patients had arterial bullet emboli, four originating in the heart, four in the thoracic aorta, and six in the abdominal aorta. Two patients died, one of cerebral infarction secondary to bullet embolus to the right carotid artery and one of an unrecognized traumatic intracardiac defect. Complications were secondary to associated injuries rather than a result of removal of bullet emboli.
References 1. Barrett NR: Foreign bodies in the cardiovascular system. 6r J Surg 37: 416, 1960. 2. Frazier TG, Belcastro VJ, lnouye WY: Trans-thoracic venous bullet embolism. J Trauma 15: 625, 1975. 3. Morton JR, Reul GL, Arbegast NR, et al: Bullet embolus to the right ventricle. Am J Surg 122: 564, 1971. 4. Kelly JL: A bullet embolism to the left femoral artery following a thoracic gunshot wound. J Thorac Cardiovasc Surg 21: 606, 1951. 5. Ledgerwood AM: The wandering bullet. Surg C/in Norfh Am 57(l): 97, 1977. 6. Padula FIT, Sandler SC, Camishion RC: Delayed bullet embolization to the heart following abdominal gunshot wound. Ann Surg 169: 599. 1969. 7. Symbas PN, Harlaftis N: Bullet emboli in the pulmonary systemic arteries. Ann Surg 165: 318, 1977.
Volume 137, February 1979
Migratory
Bullets
8. Symbas PN, Hatcher CR, Mansour KA: Projectile embolus of the lung. J Thorac Cardiovasc Surg 56: 97, 1968. 9. Taylor MT. Schlegel DM, Habeggar i%: Bullet embolism. Am J Surg 114: 457, 1967. 10. Trimble C: Arterial bullet embolism following thoracic gunshot wounds, Ann Surg 168: 911, 1968. 11. Ward PA, Suzuki A: Gunshot wound of the heart with peripheral embolization. J Thorac Cardiovasc Surg 68: 440, 1974. 12. Yajko RD, Trimble C: Arterial bullet embolism following abdominal gunshot wounds. J Trauma 14: 200. 1974. 13. Davis TD: Cited in [ I]. 14. Momm M: Ein schuss durch Lever und Aorta, tod Nach vier Wochen infolge Sepsis. Dtsch A&d Wochenschr 36: 2422, 1910. 15. Schloffer H: Bullet embolization and remarks concerning bullet injuries of the heart and great vessels. 6eitr K/in Chir 37: 698, 1903. 16. Petsas AA, Ghahramani AR, Green R: A wandering bullet. J Thorac Cardiovasc Sura 69: 954. 1975. 17. Straus R: Pulmonary embo&n caused by a lead bullet fotlowing gunshot wound of the abdomen. Arch Pathol 33: 63, 1942. 18. Borzekey R, Ueberstich WD: Schussverlatzungen des Thorax. Beitr K/in Chir 40: 243, 1903. 19. Painter W, Britt LG: Distal bullet embolism after gunshot wound of the chest. Am Surg 37: 106, 1971. 20. Bland EF, Beebe GW: Missiles in the heart. N Engl J Med 274: 1039, 1966. 21. Bartlett H, Anderson CV, Steinhoff NG: Bullet embolism to the heart. J Trauma 13: 476, 1973. 22. Hiebert CA, Gregory FJ: Bullet embolism from the head to the heart. JAMA 229: 442, 1974. 23. Moore HG, Nyhus LM, Kanar EA. et al: Gunshot wounds of major arteries. Surg Gynecol Obstet 98: 129, 1954. 24. Neerken AJ, Clement FL: Air rifle wound of the heart with embolization. JAMA 189: 579, 1964. 25. Lewis RJ, Kunderman PJ: Bullet embolus of the heart. Chest 62: 627, 1972. 26. Paltouf R: Geschossembolie der Arteria pulmonalis. Wein K/in Wochenschr 46: 602, 1933. 27. Stephenson LW, Workman RB, Aldrete JS, et al: Bullet emboli to the pulmonary artery. Ann Thorac Surg 21: 333, 1976. 28. Saylam A. Bozer AY, Kadioglu Y: Migration of a bullet from the inferior vena cava to the right pulmonary artery. Jpn Heart J 13: 572, 1972. 29. Rodriquez MA, Rodger MR: Right axillary artery bullet embolus following gunshot wound of the back. J Trauma 15: 170, 1975. 30. Saltzstein EC, Freeark RJ: Bullet embolism to the right axillaty artery following gunshot wound of the heart. Ann Surg 158: 65, 1963. 31. Wilder J: Incredible journey. Time 108: 42, 1976. 32. Dillard BM, Staple TW: Bullet embolism from the aortic arch to the popliteal artery. Arch Surg 96: 326, 1969. 33. Garzon A, Gliedman ML: Peripheral embolization of a bullet following perforation of the thoracic aorta. Ann Surg 160: 901, 1964. 34. Lam CR, McIntyre R: Air pistol injury of pulmonary artery and aorta. J Thorac Cardlovasc Surg 59: 729, 1970. 35. tiarken DE, Williams AC: Foreign bodies within the blood vascular system. Am J Surg 72: 80, 1946. 36. Harken DE: Foreign bodies in and in relation to the thoracic blood vessels and heart. I. Techniques for approaching and removing foreign bodies from the chambers of the heart. Surg Gynecol Obstet 83: 117, 1946. 37. Samson PC: Two unusual cases of war wounds of the heart. Surgery 20: 373, 1946. 38. Mattox KL, Espada R, Beall AC Jr, Jordan GL Jr: Thoracotomy in the emergency center. J Am Co// Emerg Phys 3: 13, 1974. 39. Specht: Cited in [ I]. 40. Migration of projectiles in the blood stream (editorial). Lance1 2: 395. 1917.
195
