A Lost Bullet in the Coronary Sinus: A Cautionary Tale

Area of Science:

• Cardiovascular Surgery
• Trauma Surgery
• Interventional Cardiology

Background:

• Gunshot wounds (GSW) can cause complex injuries, including vascular damage and foreign body migration.
• Venous bullet embolism is a rare but serious complication requiring careful management.
• Aortocaval fistulas present significant surgical challenges.

Observation:

• A 53-year-old male presented with an abdominal GSW, an aortic injury, and an aortocaval fistula.
• A bullet was initially visualized in the right atrium via computed tomography (CT).
• Intraoperative attempts to retrieve the bullet from the right atrium using thoracotomy and cardiopulmonary bypass were unsuccessful.

Findings:

• The bullet migrated from the right atrium to the coronary sinus postoperatively.
• Successful dislodging maneuvers repositioned the bullet into the inferior vena cava.
• Endovascular extraction of the bullet was ultimately achieved.

Implications:

• This case underscores the importance of considering bullet migration in venous embolism.
• It highlights the potential need for a hybrid approach, combining surgical and interventional techniques.
• Successful endovascular retrieval after failed open surgery demonstrates adaptability in trauma management.