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Missing Bullets: Bullet Embolization Case Series and Review of the Literature
Christine Castater1, Soroosh Noorbakhsh2, William Harousseau2
11374Morehouse School of Medicine, 71741Grady Memorial Hospital, Atlanta, GA, USA.
Insights
Bullet emboli, a rare complication of penetrating trauma, pose diagnostic and management challenges. Prompt removal of arterial and pulmonary venous bullet emboli is recommended, with endovascular approaches for stable patients and open surgery for unstable cases.
Area of Science:
- Traumatology
- Vascular Surgery
- Radiology
Background:
- Bullet embolization is a rare but serious complication of penetrating trauma, potentially causing ischemia, infarction, or cerebrovascular accidents.
- The varied presentation of bullet emboli, often unrelated to the initial injury site, poses diagnostic difficulties.
- Effective management strategies are crucial for improving outcomes in patients with bullet emboli.
Approach:
- This study presents three cases of bullet embolization managed at a Level 1 trauma center.
- The authors describe their institutional experience and management approaches, including operative and endovascular interventions.
- A review of existing literature on bullet embolization is incorporated to inform recommendations.
Key Points:
- Two patients required emergent operative intervention due to hemodynamic instability.
- One patient had successful intraoperative removal, while another required a second operation after initial minimally invasive attempts.
- The third, hemodynamically stable patient underwent successful endovascular management.
Conclusions:
- Bullet emboli represent a complex challenge in trauma care.
- Removal of all arterial bullet emboli and those in the pulmonary venous system is advised.
- Endovascular retrieval is recommended for stable patients, followed by open surgery if needed; open surgery is indicated for hemodynamically unstable patients.
Purpose:
Bullet embolization is a rare but dangerous phenomenon. Based on the location of embolization, migration of bullets can cause limb or intra-abdominal ischemia, pulmonary infarction, cardiac valve injury, or cerebrovascular accident. Bullet emboli can present a diagnostic challenge given the varied nature of complications based on location of embolization, which may not coincide with the site of initial injury. The purpose of this study is to present several cases of bullet embolization from our busy urban trauma center and make recommendations for management.
Methods:
We present 3 cases of bullet embolization seen in injured patients at our Level 1 trauma center. We describe our management of these injuries and make recommendations for management in the context of our institutional experience and comment on the available literature regarding bullet embolization.
Results:
Two of our patients presented in extremis and required operative intervention to achieve stability. The intravascular missile was discovered intraoperatively in one patient and removed in the operating room, while the missile was discovered on postoperative imaging in another patient and again removed operatively after an unsuccessful attempt at minimally invasive retrieval. Our third patient remained hemodynamically stable throughout his hospitalization and had endovascular management of his bullet embolus.
Conclusion:
Bullet emboli present a challenging complication of penetrating trauma. We recommend removal of all arterial bullet emboli and those within the pulmonary venous system. In hemodynamically stable patients, we recommend initial attempts of endovascular retrieval followed by open surgical removal. We recommend open removal in cases of hemodynamic instability.
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