Carotid Artery Injury With a Migrating Venous Missile Embolus: A Unique Sequela of Shotgun Neck Trauma

Ballistic injuries to the neck carry a significant risk of injury to the airway, vascular, and aerodigestive structures. We report the case of a young adult who sustained a close-range shotgun injury to the left anterior neck. Despite hemodynamic stability and an initially intact airway, CT angiography (CTA) was unable to adequately visualize the carotid artery or internal jugular vein (IJV) because of extensive metallic artifact from multiple retained birdshot pellets. The patient underwent urgent operative exploration, during which numerous pellets were identified within the soft tissues, including several that were adherent to the left IJV and common carotid artery. Multiple venous injuries were repaired, and a full-thickness carotid artery injury required segmental resection with primary end-to-end anastomosis. Postoperatively, a radiographic fragment near the cardiac border was confirmed by echocardiography to be a venous missile embolus lodged in the right ventricular apex. After multidisciplinary review, the fragment was managed nonoperatively. The patient recovered without neurologic deficits and was discharged home the following day. This case emphasizes the importance of operative exploration when CTA is limited by artifact and highlights evidence-based selective nonoperative management of intracardiac and intrapulmonary missile emboli.