Pulmonary artery bullet embolism - Case report and review

INTRODUCTION Bullet embolism, an uncommon but serious complication of penetrating vascular trauma, poses a unique clinical challenge for the trauma physician. Migration of bullets can lead to infection, thrombosis, ischemia, hemorrhage and death. PRESENTATION OF CASE We report a patient in whom a bullet embolized from the left femoral vein to the right pulmonary artery, a situation ultimately managed by observation alone. DISCUSSION Bullet embolism should be suspected when the number of penetrating entry wounds exceeds the number of exit wounds. Patients with radiographic studies showing a bullet outside the established trajectory require further evaluation. Most bullet emboli are arterial, and are generally symptomatic presenting with early signs of ischemia. Venous emboli are less common, and they are generally asymptomatic. Most venous bullet emboli travel in the direction of the blood flow and may lodge in the pulmonary arterial tree causing serious complications. Management of bullet emboli in the pulmonary arterial tree remains controversial and specific guidelines have not been clearly established. However, the available data in the literature suggest that pulmonary artery embolism can be observed in the asymptomatic patient. CONCLUSION Symptomatic pulmonary bullet emboli should be managed with endovascular retrieval when available or operative therapy. Asymptomatic intravascular bullet emboli may be managed conservatively as seen in our patient.