The Pearls and Pitfalls of a Migrating Bullet Embolus

Venous bullet embolism is an exceedingly rare trauma diagnosis that presents diagnostic and therapeutic challenges. We present the case of a 32-year-old man who sustained multiple gunshot wounds with a venous bullet embolism to the right pulmonary artery. Imaging at first demonstrated a bullet lodged within the right lower lobe. The patient underwent multiple bronchoscopies and ultimately was found to have a bullet embolus in the right pulmonary artery. Repeat endovascular attempts failed at removal, and during a right thoracotomy, the bullet migrated to the left pulmonary artery. Coil embolization of the left lower lobe pulmonary artery was performed, and the patient was found to be asymptomatic at the 1-year follow-up. To our knowledge, this is the first case to demonstrate coil embolization of the pulmonary artery as a method of endovascular treatment for a venous bullet embolus. We present this case report to emphasize the difficulty in diagnosis, localization, and management of a migratory bullet within the pulmonary circulation.