An unusual shot-retrograde transthoraco-abdominal venous bullet embolization

A 72-year-old gentleman was brought to the emergency department, after sustaining an allegedly accidental airgun-shot injury to the right side of his neck. A chest radiograph and plain CT chest revealed the bullet lodged deeply in the soft tissues of the right side of the neck. He was taken up for an emergency neck exploration for foreign body removal. Peroperatively, the bullet was observed to be lodged in the right internal jugular vein. During the attempt to retrieve the bullet, it inadvertently migrated downstream. An intraoperative fluoroscopy revealed the bullet in the thorax near the level of the diaphragm. A subsequent CT chest revealed an intracardiac location of the bullet in the right atrium, at its junction with the inferior vena cava. When it was decided to attempt a percutaneous endovascular retrieval strategy, fluoroscopic imaging of the chest in the cardiac catheterization lab, revealed that the bullet was no longer in the thorax, and had migrated again, and was found to be located in the left side of the pelvis. A subsequent venogram showed the bullet to be lodged in a tributary of the left external iliac vein. It was then snared percutaneously, through the left femoral vein, and delivered through a venotomy. Vascular bullet embolization is a rare phenomenon, especially, as in this case, a retrograde venous embolization with a transthoraco-abdominal course. The treatment of bullet embolization, whether surgical or endovascular, depends on the final destination site, symptomatic status and propensity for complications.