Intravascular Missile Embolization in Childhood: Report of a Case, Literature Review, and Recommendations for Management By Malek Massad
and Michel S. Slim
Beirut, Lebanon 0 A collective review of 20 cases of missile embolization among children (1961 to 1988) is analyzed, one case added, and guidelines for diagnosis and management are outlined. Causative agents were bullets (14 patients), pellets (6). and fragments (2). Their trajectory was arterioarterial (1 I), venovenous (5). paradoxical (4). and mixed (1). Diagnosis was suspected when an exit wound was absent and the foreign body was traced on regional x-ray. Embolization was predominantly to the legs, with a tendency for the left (5 of 8 cases). Upper extremity emboli were exclusively to the right. Only one of five cardiac entries required closure to control bleeding compared with four of six aortic. Embolectomy was performed in 16 patients. The overall mortality rate was 9.5%. Factors predicting a favorable outcome are early presentation, diagnosis, and intervention; location of cardiovascular entry and embolus site: and presence of soft tissue tamponade at entry wound. Although embolectomy for cerebral, asymptomatic pulmonary arterial, and silent venous emboli is controversial, universal agreement prevails regarding removal of systemic arterial as well as venous emboli that are potentially problematic. 0 1990 by W.B. Saunders Company. INDEX WORDS:
Missile emboli, childhood.
C
OMMON intravascular foreign body emboli among children are fractured pacing wires, intravenous infusion tubings, central monitoring catheters, and air emboli. Rarely reported in this age group is embolization of shotgun pellets, gunshot bullets, and fragments of shells or heavy mortar artillery. In a collective review of the literature (1961 to 1988) only 20 such cases have been reported in that age group.“18 The majority of these cases are either accidental or the result of civilian war injuries. Lately, we reported five cases of missile emboli’ to which we are now adding another case from a pool of 1,500 cases of vascular injuries that presented to the American University of Beirut Medical Center (AUBMC) over an 1 l-year period of civil war (1976 to 1987). The purpose of this paper is (1) to report a new case, the youngest described; (2) to analyze the 21 cases
From the Divisions of Pediatric and Cardiothoracic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon. Address reprint requests to Malek Massad, MD, 5020 S Lakeshore Dr. 2414N. Chicago, IL 60615. 8 1990 by W.B. Saunders Company. 0022-3468/90/2512-0032$03.00/0
1292
reported over the past 27 years; and (3) to highlight factors that determine a favorable prognosis despite an expected fatal outcome. CASE
REPORT
A S-year old boy presented to the emergency unit after sustaining
multiple fragment injuries to the right side of the chest. On admission, he was in acute respiratory distress but had stable vital signs. After maintaining a patent airway, administration of oxygen by mask, and insertion of a venous cannula, a plain film of the chest was taken and showed an intrathoracic fragment posteriorly on the left and a marked widening of the superior mediastinum. Because of his critical condition and the radiological findings suggestive of a major vessel injury, the chest was explored through a bilateral transsternal thoracotomy. The thymus gland was severely hemorrhagic. After evacuating a large hematoma from the superior mediastinum, a small entry site in the ascending aorta was identified and was closed with pledgetted sutures. On further inspection, the shrapnel visualized radiologically was palpated through the wall of the descending aorta at the level of the ligamenturn arteriosum. The aorta was partially clamped, a small metallic fragment was extracted, and an aortoplasty was performed. Postoperatively, the patient had a smooth recovery and good long-term anatomical and functional results. DISCUSSION
In an extensive review of the literature since 1961, we have collected 20 cases of missile embolization, 16 years of age or less, to which we have added one. There were 19 boys and 2 girls, whose ages ranged from 5 to 16 years. The causative agent was a bullet in 14 (66.7%), single or multiple pellets in 5 (23.8%), and low-velocity fragments in 2 (9.5%). Based on entry and destination, the emboli were classified as arterioarterial(ll, 52.4%), venoarterial (3, 14.3%), arteriovenous (1,4.8%), venovenous (5,23.8%), and mixed caused by multiple pellets (1,4.8%). The site of entry was the aorta in six patients (28.6%), heart in five (23.8%), pulmonary vein in two (9.5%), and vena cavae in another two (9.5%); the pulmonary artery (PA), vertebral artery, superior sagital sinus, and the internal jugular, subclavian, and renal veins were involved in one patient each (28.6%). In eight patients, the embolization was to the lower extremity (5 left, 3 right) and in one to the right internal iliac artery (ie, 42.8% of all cases). In five, the embolus traveled to the upper extremity, neck vessels (23.8%), and right middle cerebral artery. Upper extremity emboli involved the right side exclusively. Radiological confirmation of embolization was estab-
Journal of fediafric Surgery, Vol 25, No 12 (December), 1990: pp 1292-1294
MISSILE EMBOLI IN CHILDHOOD
1293
lished by angiography in eight patients and by echocardiography in three. In 10 patients, the clinical diagnosis was established after plain radiography. Suturing of the vascular entry site was performed in eight patients with no operative mortality. In the remaining 11, palliative surgical treatment or observant management of the entry site was performed. Two of the latter died, none of whom had an entry site related death. Only one of the five cardiac cases required emergency wound closure compared with four of the six with aortic wounds. Embolectomy was performed in 16 patients, all surviving except one whose injury was not recognized initially who returned 24 hours later with a pulseless right leg, and eventually died of gangrene-related sepsis. Interestingly, percutaneous embolectomy was successfully performed on one patient with a right ventricular (RV) bullet embolus. No attempt at extracting the embolus was made in five patients with PA, RV, posterior cerebral, and brachioaxillary arterial emboli. In this group, one patient with cerebellar and midbrain infarctions developed neurogenic pulmonary edema and died. The overall mortality rate was 9.5%. All survivors were symptom-free except one with craniocerebral injury who had residual focal epilepsy. No long-term follow-up was available on four patients with retained emboli. One patient with a retained RV bullet was doing well for 2 years after injury. Among the factors influencing the site of embolization are the size and shape of the missile, the point of entry into the cardiovascular system, the force and direction of blood flow, the relative size and angle of take-off of the vascular branches, and the position of the patient immediately after injury. The larger the embolus is, the more frequently it will produce distal ischemia, and the more irregular it is, the more frequently it will carry foreign material with it, producing secondary trauma or infection. Extracranial systemic arterial emboli should be extracted soon after recognition. Early embolectomy is
advocated, because real dangers exist regarding sepsis, thrombus propagation, further embolization, or stenosis. With peripheral emboli, particularly bullet or shell fragments, embolectomy should be performed at the site of embolus because manipulation of the missile within the vessel lumen may cause intimal tears. Pellet emboli from the heart or ascending aorta have a high potential for cerebral embolization, and preferentially lodge at the origin of the middle cerebral artery. The mortality rate with cerebral embolization is 25% to 33%,19 and does not appear to be related to the method of treatment. The diagnosis of PA emboli is made by plain chest radiography and lung scanning, and may be confirmed by arteriography. A controversy exists regarding the method of management. Emboli may migrate freely from one branch of the PA to another, particularly during thoracotomy and manipulation. The use of PA balloon catheter preoperatively may be helpful in locating and immobilizing the foreign body. In the case when pulmonary infarction occurs, ligation of the artery and lobectomy should be performed. In asymptomatic cases of PA embolization, observant nonoperative management may be elected. Projectiles in the venous system with any potential for local or systemic complications should be evaluated with angiography and removed by direct exposure of the involved vessel. Selective observation may be adequate for late asymptomatic emboli with insignificant circulatory sequelae. RV emboli usually get trapped beneath the tricuspid valve in the chordopapillary apparatus or in the ventricular trabeculae during initial transit. Although embolectomy has not been undertaken in all cases, and a clinical reason for extraction of the missile does not always exist, removal of the missile using cardiopulmonary bypass for fear of further embolization, thrombosis, infection, or cardiac neurosis is justifiable. Nonoperative percutaneous extraction of a bullet under fluoroscopy through the internal jugular vein using the Caves-Schulz bioptome has also been reported.*’
REFERENCES
1. Abdo F, Massad M, Slim MS, et al: Wandering intravascular missiles: Report of five cases from the Lebanon War. Surgery 103:376-380, 1988 2. Kinmonth JB, Burton JD, Longmore DB, et al: Gunshot wounds of the heart with embolism. Br Med J 2:1666-1668.1961 3. Garzon A, Gliedman ML: Peripheral embolization of a bullet following perforation of the thoracic aorta. Ann Surg 1601901-904, 1964 4. Stanford W, Crosby VG, Pike JD, et al: Gunshot wounds of the thoracic aorta with peripheral embolization of the missile: A case report. Ann Surg 165:139-141, 1967
5. Hardy JD, Timmis HH: Repair of intrathoracic gunshot injuries. Ann Surg 169:906-913, 1969 6. Blackford J, Bowers JD, Taylor PH. et al: Pellet embolism to the internal iliac artery. Am J Surg 1l&469-471, 1969 7. Lam CR, McIntyre R: Air-pistol injury of the pulmonary artery and aorta. Report of a case with peripheral embolization of pellet and residual aorticopulmonary fistula. J Thorac Cardiovasc Surg 59~729-732, 1970 8. Ptsas AA, Ghahramani AR, Green R: A wandering bullet. Successful removal and a simple technique to prevent its migration. J Thorac Cardiovasc Surg 69:954-956, 1975 9. Fisk RL, Addetia A, Gelfand ET, et al: Missile migration from
1294
lung to heart with delayed systemic embolization. Chest 72:534-535, 1977 10. Duerr S, Cocco T: Gunshot wound of the abdomen with cerebral embolization. J Trauma 17:155-157, 1977 11. Reines HD, Dill L, Saad S, et al: Neurogenic pulmonary edema and missile emboli. J Trauma 20:698-701, 1980 12. Nebme AE: Intracranial bullet migrating to pulmonary artery. J Trauma 20:344-346, 1980 13. Hartzler GO: Percutaneous transvenous removal of a bullet embolus to the right ventricle. J Thorac Cardiovasc Surg 80:153155,198O 14. Patten EL, Morales HE: Bullet emboli to the pulmonary artery: A rare occurrence. J Trauma 22:801-802, 1982 15. Vascik JM, TEW JM Jr: Foreign body embolization of the middle cerebral artery: Review of the literature and guidelines for management. Neurosurgery 11:532-536, 1982
MASSAD AND SLIM
16. Burkitt DS, Shasmana JP, Mortensen NJ, et al: Bullet embolism to the popliteal artery following air rifle injury of the thoracic aorta. Br J Surg 71:61, 1984 17. Schowengerdt CG, Vasko JS, Craenen JM, Teske DW: Airgun pellet injury of the heart with popliteal embolus. Ann Thorac Surg 40:393-395,1985 18. Amsel BJ, Van Der Mast M, De Bock L, et al: The importance of two-dimensional echocardiography in the location of a bullet embolus to the right ventricle. Ann Thorac Surg 46:102-103, 1988 19. Meyer FB, Sundt TM, Liepgros DG: Middle cerebral artery embolectomy, in Sundt TM (ed): Occlusive Cerebrovascular Disease. Diagnosis and Surgical Management (ed 1). Philadelphia, PA, Saunders, 1977, pp 467-476 20. Hartzler GO: Percutaneous transvenous removal of a bullet embolus to the right ventricle. J Thorac Cardiovasc Surg 80:153155,198O
and Michel S. Slim
Beirut, Lebanon 0 A collective review of 20 cases of missile embolization among children (1961 to 1988) is analyzed, one case added, and guidelines for diagnosis and management are outlined. Causative agents were bullets (14 patients), pellets (6). and fragments (2). Their trajectory was arterioarterial (1 I), venovenous (5). paradoxical (4). and mixed (1). Diagnosis was suspected when an exit wound was absent and the foreign body was traced on regional x-ray. Embolization was predominantly to the legs, with a tendency for the left (5 of 8 cases). Upper extremity emboli were exclusively to the right. Only one of five cardiac entries required closure to control bleeding compared with four of six aortic. Embolectomy was performed in 16 patients. The overall mortality rate was 9.5%. Factors predicting a favorable outcome are early presentation, diagnosis, and intervention; location of cardiovascular entry and embolus site: and presence of soft tissue tamponade at entry wound. Although embolectomy for cerebral, asymptomatic pulmonary arterial, and silent venous emboli is controversial, universal agreement prevails regarding removal of systemic arterial as well as venous emboli that are potentially problematic. 0 1990 by W.B. Saunders Company. INDEX WORDS:
Missile emboli, childhood.
C
OMMON intravascular foreign body emboli among children are fractured pacing wires, intravenous infusion tubings, central monitoring catheters, and air emboli. Rarely reported in this age group is embolization of shotgun pellets, gunshot bullets, and fragments of shells or heavy mortar artillery. In a collective review of the literature (1961 to 1988) only 20 such cases have been reported in that age group.“18 The majority of these cases are either accidental or the result of civilian war injuries. Lately, we reported five cases of missile emboli’ to which we are now adding another case from a pool of 1,500 cases of vascular injuries that presented to the American University of Beirut Medical Center (AUBMC) over an 1 l-year period of civil war (1976 to 1987). The purpose of this paper is (1) to report a new case, the youngest described; (2) to analyze the 21 cases
From the Divisions of Pediatric and Cardiothoracic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon. Address reprint requests to Malek Massad, MD, 5020 S Lakeshore Dr. 2414N. Chicago, IL 60615. 8 1990 by W.B. Saunders Company. 0022-3468/90/2512-0032$03.00/0
1292
reported over the past 27 years; and (3) to highlight factors that determine a favorable prognosis despite an expected fatal outcome. CASE
REPORT
A S-year old boy presented to the emergency unit after sustaining
multiple fragment injuries to the right side of the chest. On admission, he was in acute respiratory distress but had stable vital signs. After maintaining a patent airway, administration of oxygen by mask, and insertion of a venous cannula, a plain film of the chest was taken and showed an intrathoracic fragment posteriorly on the left and a marked widening of the superior mediastinum. Because of his critical condition and the radiological findings suggestive of a major vessel injury, the chest was explored through a bilateral transsternal thoracotomy. The thymus gland was severely hemorrhagic. After evacuating a large hematoma from the superior mediastinum, a small entry site in the ascending aorta was identified and was closed with pledgetted sutures. On further inspection, the shrapnel visualized radiologically was palpated through the wall of the descending aorta at the level of the ligamenturn arteriosum. The aorta was partially clamped, a small metallic fragment was extracted, and an aortoplasty was performed. Postoperatively, the patient had a smooth recovery and good long-term anatomical and functional results. DISCUSSION
In an extensive review of the literature since 1961, we have collected 20 cases of missile embolization, 16 years of age or less, to which we have added one. There were 19 boys and 2 girls, whose ages ranged from 5 to 16 years. The causative agent was a bullet in 14 (66.7%), single or multiple pellets in 5 (23.8%), and low-velocity fragments in 2 (9.5%). Based on entry and destination, the emboli were classified as arterioarterial(ll, 52.4%), venoarterial (3, 14.3%), arteriovenous (1,4.8%), venovenous (5,23.8%), and mixed caused by multiple pellets (1,4.8%). The site of entry was the aorta in six patients (28.6%), heart in five (23.8%), pulmonary vein in two (9.5%), and vena cavae in another two (9.5%); the pulmonary artery (PA), vertebral artery, superior sagital sinus, and the internal jugular, subclavian, and renal veins were involved in one patient each (28.6%). In eight patients, the embolization was to the lower extremity (5 left, 3 right) and in one to the right internal iliac artery (ie, 42.8% of all cases). In five, the embolus traveled to the upper extremity, neck vessels (23.8%), and right middle cerebral artery. Upper extremity emboli involved the right side exclusively. Radiological confirmation of embolization was estab-
Journal of fediafric Surgery, Vol 25, No 12 (December), 1990: pp 1292-1294
MISSILE EMBOLI IN CHILDHOOD
1293
lished by angiography in eight patients and by echocardiography in three. In 10 patients, the clinical diagnosis was established after plain radiography. Suturing of the vascular entry site was performed in eight patients with no operative mortality. In the remaining 11, palliative surgical treatment or observant management of the entry site was performed. Two of the latter died, none of whom had an entry site related death. Only one of the five cardiac cases required emergency wound closure compared with four of the six with aortic wounds. Embolectomy was performed in 16 patients, all surviving except one whose injury was not recognized initially who returned 24 hours later with a pulseless right leg, and eventually died of gangrene-related sepsis. Interestingly, percutaneous embolectomy was successfully performed on one patient with a right ventricular (RV) bullet embolus. No attempt at extracting the embolus was made in five patients with PA, RV, posterior cerebral, and brachioaxillary arterial emboli. In this group, one patient with cerebellar and midbrain infarctions developed neurogenic pulmonary edema and died. The overall mortality rate was 9.5%. All survivors were symptom-free except one with craniocerebral injury who had residual focal epilepsy. No long-term follow-up was available on four patients with retained emboli. One patient with a retained RV bullet was doing well for 2 years after injury. Among the factors influencing the site of embolization are the size and shape of the missile, the point of entry into the cardiovascular system, the force and direction of blood flow, the relative size and angle of take-off of the vascular branches, and the position of the patient immediately after injury. The larger the embolus is, the more frequently it will produce distal ischemia, and the more irregular it is, the more frequently it will carry foreign material with it, producing secondary trauma or infection. Extracranial systemic arterial emboli should be extracted soon after recognition. Early embolectomy is
advocated, because real dangers exist regarding sepsis, thrombus propagation, further embolization, or stenosis. With peripheral emboli, particularly bullet or shell fragments, embolectomy should be performed at the site of embolus because manipulation of the missile within the vessel lumen may cause intimal tears. Pellet emboli from the heart or ascending aorta have a high potential for cerebral embolization, and preferentially lodge at the origin of the middle cerebral artery. The mortality rate with cerebral embolization is 25% to 33%,19 and does not appear to be related to the method of treatment. The diagnosis of PA emboli is made by plain chest radiography and lung scanning, and may be confirmed by arteriography. A controversy exists regarding the method of management. Emboli may migrate freely from one branch of the PA to another, particularly during thoracotomy and manipulation. The use of PA balloon catheter preoperatively may be helpful in locating and immobilizing the foreign body. In the case when pulmonary infarction occurs, ligation of the artery and lobectomy should be performed. In asymptomatic cases of PA embolization, observant nonoperative management may be elected. Projectiles in the venous system with any potential for local or systemic complications should be evaluated with angiography and removed by direct exposure of the involved vessel. Selective observation may be adequate for late asymptomatic emboli with insignificant circulatory sequelae. RV emboli usually get trapped beneath the tricuspid valve in the chordopapillary apparatus or in the ventricular trabeculae during initial transit. Although embolectomy has not been undertaken in all cases, and a clinical reason for extraction of the missile does not always exist, removal of the missile using cardiopulmonary bypass for fear of further embolization, thrombosis, infection, or cardiac neurosis is justifiable. Nonoperative percutaneous extraction of a bullet under fluoroscopy through the internal jugular vein using the Caves-Schulz bioptome has also been reported.*’
REFERENCES
1. Abdo F, Massad M, Slim MS, et al: Wandering intravascular missiles: Report of five cases from the Lebanon War. Surgery 103:376-380, 1988 2. Kinmonth JB, Burton JD, Longmore DB, et al: Gunshot wounds of the heart with embolism. Br Med J 2:1666-1668.1961 3. Garzon A, Gliedman ML: Peripheral embolization of a bullet following perforation of the thoracic aorta. Ann Surg 1601901-904, 1964 4. Stanford W, Crosby VG, Pike JD, et al: Gunshot wounds of the thoracic aorta with peripheral embolization of the missile: A case report. Ann Surg 165:139-141, 1967
5. Hardy JD, Timmis HH: Repair of intrathoracic gunshot injuries. Ann Surg 169:906-913, 1969 6. Blackford J, Bowers JD, Taylor PH. et al: Pellet embolism to the internal iliac artery. Am J Surg 1l&469-471, 1969 7. Lam CR, McIntyre R: Air-pistol injury of the pulmonary artery and aorta. Report of a case with peripheral embolization of pellet and residual aorticopulmonary fistula. J Thorac Cardiovasc Surg 59~729-732, 1970 8. Ptsas AA, Ghahramani AR, Green R: A wandering bullet. Successful removal and a simple technique to prevent its migration. J Thorac Cardiovasc Surg 69:954-956, 1975 9. Fisk RL, Addetia A, Gelfand ET, et al: Missile migration from
1294
lung to heart with delayed systemic embolization. Chest 72:534-535, 1977 10. Duerr S, Cocco T: Gunshot wound of the abdomen with cerebral embolization. J Trauma 17:155-157, 1977 11. Reines HD, Dill L, Saad S, et al: Neurogenic pulmonary edema and missile emboli. J Trauma 20:698-701, 1980 12. Nebme AE: Intracranial bullet migrating to pulmonary artery. J Trauma 20:344-346, 1980 13. Hartzler GO: Percutaneous transvenous removal of a bullet embolus to the right ventricle. J Thorac Cardiovasc Surg 80:153155,198O 14. Patten EL, Morales HE: Bullet emboli to the pulmonary artery: A rare occurrence. J Trauma 22:801-802, 1982 15. Vascik JM, TEW JM Jr: Foreign body embolization of the middle cerebral artery: Review of the literature and guidelines for management. Neurosurgery 11:532-536, 1982
MASSAD AND SLIM
16. Burkitt DS, Shasmana JP, Mortensen NJ, et al: Bullet embolism to the popliteal artery following air rifle injury of the thoracic aorta. Br J Surg 71:61, 1984 17. Schowengerdt CG, Vasko JS, Craenen JM, Teske DW: Airgun pellet injury of the heart with popliteal embolus. Ann Thorac Surg 40:393-395,1985 18. Amsel BJ, Van Der Mast M, De Bock L, et al: The importance of two-dimensional echocardiography in the location of a bullet embolus to the right ventricle. Ann Thorac Surg 46:102-103, 1988 19. Meyer FB, Sundt TM, Liepgros DG: Middle cerebral artery embolectomy, in Sundt TM (ed): Occlusive Cerebrovascular Disease. Diagnosis and Surgical Management (ed 1). Philadelphia, PA, Saunders, 1977, pp 467-476 20. Hartzler GO: Percutaneous transvenous removal of a bullet embolus to the right ventricle. J Thorac Cardiovasc Surg 80:153155,198O
