Bullet retrieval from the right hepatic vein using a controlled endovascular and transhepatic approach

Venous bullet embolism is a rare complication of trauma. We describe a patient who sustained a gunshot wound. Computed tomography revealed antegrade embolization of the bullet to the right hepatic vein (RHV). The risk of not retrieving the bullet embolus and subsequent embolization to the pulmonary circulation includes pulmonary artery thrombosis, bleeding, or abscess formation. The bullet was retrieved through right internal jugular vein access; assisted by percutaneous transhepatic repositioning and endovascular balloon-immobilization of the bullet. The balloon served to "isolate" the bullet within the RHV to avoid the risk of endovascular migration to the pulmonary circulation. Transhepatic access allowed repositioning of the bullet within the RHV leading to successful snare retrieval. This technique demonstrates advantages of percutaneous and endovascular accesses, that repositioned and immobilized the bullet in the RHV to accomplish controlled endovascular retrieval.