Intravascular projectile embolism from firearm injuries: How did it get there?

Intravascular projectile embolization is a rare but potentially fatal complication of penetrating firearm injury, in which a low-energy projectile enters the cardiovascular system and migrates to a site remote from the wound of entry. Because the projectile comes to rest far from its expected trajectory, the diagnosis rests on imaging and may be overlooked. This pictorial essay reviews the classification and imaging of ballistic embolization from a mechanism-based, side-of-circulation perspective, illustrated by three cases spanning antegrade and retrograde migration within both the left and right circulation. CT angiography is the cornerstone of diagnosis, classification, and treatment planning; the projectile-trajectory mismatch is the key diagnostic clue, and classification by side of circulation determines management. Awareness of these atypical migration patterns helps radiologists maintain an appropriate search pattern, anticipate unexpected embolic sites, and communicate urgent findings that direct multidisciplinary management.