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Ali M Hassan

Haitham Elsamaloty

John J Fath

Roger S Cooley

Thomas A Schwann

Thomas J Papadimos

Patient Safety in Surgery

English

PubMed

Abstract Background Vascular embolization of a projectile discharged from a weapon is a rare event. In this report a hunter's errant gunshot struck a farmer in the left chest. Case report The projectile was lodged between the apex of the heart and the diaphragm. The patient was treated non-operatively and was discharged home only to return to the emergency department with chest pain and subsequent identification of the projectile in the left inferior pulmonary vein. Operative management consisted of a median sternotomy, cardiopulmonary bypass, and a pulmonary venectomy. Conclusion He was subsequently discharged home and recovered uneventfully.</p

Schwann Thomas A

Fath John J

Papadimos Thomas J

Cooley Roger S

Hassan Ali M

Elsamaloty Haitham

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Pulmonary bullet embolism – a safe treatment strategy of a potentially fatal injury: a case report

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BioMed CentralPatient Safety in Surgery
ssOpen AcceCase report
Pulmonary bullet embolism – a safe treatment strategy of a 
potentially fatal injury: a case report
Ali M Hassan1, Roger S Cooley1, Thomas J Papadimos*1, John J Fath2, 
Thomas A Schwann2 and Haitham Elsamaloty3
Address: 1Department of Anesthesiology, University of Toledo, College of Medicine, 3000 Arlington Avenue, Toledo, Ohio 43614, USA, 
2Department of Surgery, University of Toledo, College of Medicine, 3000 Arlington Avenue, Toledo, Ohio 43614, USA and 3Department of 
Radiology, University of Toledo, College of Medicine, 3000 Arlington Avenue, Toledo, Ohio 43614, USA
Email: Ali M Hassan - ali.hassan@utoledo.edu; Roger S Cooley - cooley@wowway.com; 
Thomas J Papadimos* - thomas.papadimos@utoledo.edu; John J Fath - john.fath@oakwood.org; 
Thomas A Schwann - thomas.schwann@utoledo.edu; Haitham Elsamaloty - haitham.elsamaloty@utoledo.edu
* Corresponding author    
Abstract
Background: Vascular embolization of a projectile discharged from a weapon is a rare event. In
this report a hunter's errant gunshot struck a farmer in the left chest.
Case report: The projectile was lodged between the apex of the heart and the diaphragm. The
patient was treated non-operatively and was discharged home only to return to the emergency
department with chest pain and subsequent identification of the projectile in the left inferior
pulmonary vein. Operative management consisted of a median sternotomy, cardiopulmonary
bypass, and a pulmonary venectomy.
Conclusion: He was subsequently discharged home and recovered uneventfully.
Background
Embolism of projectiles is a rare event, in the Vietnam
War this occurred in 0.3% of 7500 casualties [1]. There are
fewer than 200 cases in the literature since 1900 [2]. This
includes all known data from both World Wars and all
conflicts in the last century [3-6]. The mortality rate for
penetrating gunshot wounds to the chest varies between
14.3% and 36.8% [7]. A missile embolus to the right heart
and pulmonary bed after penetrating chest trauma is
uncommon [6,8,9], and such an embolus to the left ven-
tricle is even more rare [9-13]. Embedded missiles in the
left heart may be observed if they are asymptomatic [14],
but if not, then there is a risk of embolization or thrombus
and must therefore be removed [11,14,15]. A pulmonary
embolus is, indeed, a rare event, and the majority of such
patients will be without symptoms, but cough, dyspnea,
chest pain, and/or hemoptysis may occur [14-17]. Here
we report a unique case of unexplained migration of a
pulmonary projectile into the left inferior pulmonary
vein. This occurred without clinically apparent interven-
ing damage to the pericardium, heart, lung or vascular
structures.
Case report
While working in his field, a 23 year old farmer sustained
a gunshot wound to his left upper chest secondary to a
hunter's errant shot (a 410 slug, 2.5 inches in length). The
projectile entered the left anterior chest between the sec-
ond and third ribs. Emergency medical services were
immediately called. They arrived promptly and found the
Published: 19 June 2009
Patient Safety in Surgery 2009, 3:12 doi:10.1186/1754-9493-3-12
Received: 16 April 2009
Accepted: 19 June 2009
This article is available from: http://www.pssjournal.com/content/3/1/12
© 2009 Hassan et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Patient Safety in Surgery 2009, 3:12 http://www.pssjournal.com/content/3/1/12patient to be hypotensive with a systolic blood pressure of
70 mmHg and with diminished breath sounds over the
left lung field. The emergency personnel treated a pre-
sumed pneumothorax with placement of a large bore 14-
gauge catheter into the upper left chest. The patient's
hemodynamics and breath sounds improved. The patient
arrived at The University of Toledo Medical Center Emer-
gency Department (ED) via life flight helicopter with two
large bore peripheral intravenous lines in place. He had
received 2 liters of intravenous crystalloid in transit.
Examination in the ED showed the patient to be hemody-
namically stable with good breath sounds and no hemo-
ptysis. The patient presented with a Glasgow Coma Scale
of 15, a blood pressure of 128/59 mm Hg, a heart rate of
108/minute, respiratory rate of 20/minute, and an oxygen
saturation of 97% on room air. The patient related that he
had no allergies, no significant prior medical or surgical
history, and was otherwise healthy. Upon examination an
entry wound was evident in the left anterior chest and no
exit wound was noted. A chest x-ray was ordered, and
demonstrated a 15% left sided pneumothorax. The pro-
jectile was located in the inferior portion of the left pleural
cavity. Bilateral 36 French chest tubes were placed (the
right chest tube was prophylactic), and the patient was
intubated with an 8.0 tracheal tube, sedated with propo-
fol, and taken for computerized tomography (CT) scan
with contrast. The CT scan confirmed the left pneumoth-
orax, with appropriate placement of the bilateral chest
tubes and the endotracheal tube. The CT scan also identi-
fied the projectile path through the left lung parenchyma.
The integrity of all major vessels and tracheobronchial
segments was confirmed. The projectile was identified
between the apex of the heart and the diaphragm (see fig-
ures 1, 2).
The patient was admitted to the surgical intensive care
unit (SICU), where he remained hemodynamically stable.
Serial roentgenograms revealed the projectile remained
immobile. He was weaned from the ventilator and extu-
bated on hospital day 2 in the SICU. The right chest tube
was removed on day 3, and the left chest tube was
removed on day 5. The chest roentgenogram on day 5
showed no recurrent pneumothorax. The patient was dis-
charged on the afternoon of the fifth hospital day with
elective surgery planned for the removal of the projectile.
The patient subsequently returned to the ED on the third
post discharge day with complaints of pain at the left chest
tube insertion site. He denied any interval hemoptysis or
shortness of breath. Chest roentgenogram revealed the
projectile had migrated to a position near the left atrium.
CT examination demonstrated the projectile was in the
heart or, possibly, in a vessel near the heart (see figure 3).
An urgent cardiothoracic intervention was scheduled on
the same day. After induction of general anesthesia, an 8.0
single lumen tube was placed. A left endobronchial
blocker was placed to facilitate single lung ventilation as
required. A right internal jugular introducer was inserted
with subsequent insertion of a pulmonary artery catheter.
Additionally, a 20 gauge right radial arterial line was
placed. Transesophageal echocardiography (TEE) moni-
toring was used to monitor cardiac function throughout
the case. Initial TEE and intraoperative fluoroscopy fur-
ther confirmed the roentgenographic and CT findings sug-
Scout film of chest with bullet evident in left chestFig re 1
Scout film of chest with bullet evident in left chest.
The initial computerized tomography scan demonstrating the bullet positi n be ween the heart apex d diaphragm (see arrow)Figure 2
The initial computerized tomography scan demon-
strating the bullet position between the heart apex 
and diaphragm (see arrow).Page 2 of 4
(page number not for citation purposes)
Patient Safety in Surgery 2009, 3:12 http://www.pssjournal.com/content/3/1/12gesting the projectile was in or near the left atrium. A
median sternotomy was performed to explore the left tho-
racic cavity and revealed that the pericardial sac and heart
surfaces were intact. In addition, the major vessels and
lung surfaces also appeared to have no defects. Cardiopul-
monary bypass was instituted, and exploration of all four
cardiac chambers was done via incision of the biatrial
groove. No palpable evidence of the projectile was noted
at that time. Repeat TEE and fluoroscopy showed the pro-
jectile to be in the same position. Re-exploration of the
posterior aspect of the heart revealed a palpable object in
the left inferior pulmonary vein. A venotomy of the left
inferior pulmonary vein was performed and the projectile
was removed intact. After careful reinspection of the vas-
culature and heart, two chest tubes were placed and the
thorax was closed. The patient was transferred to the
SICU.
A bronchosopy was done on postoperative day 3 and con-
firmed that the left tracheobronchial tree was intact with
no evidence of bleeding. The patient was extubated with
subsequent discontinuation of the chest tubes. He recov-
ered uneventfully and was discharged on postoperative
day six.
Discussion
There are two general scenarios for projectiles striking a
body: high speed (military) and low speed (civilian)
[18,19]. In the case of a high-speed projectile impacting a
body, the projectile will enter the body, travel in a straight
line and exit the body. Secondary internal damage is due
to bone fragments or viscoelastic shock waves disrupting
other structures. With a low speed impact, the projectile
may not travel in a straight line, and it may not exit the
body. Tissue planes, bone, or other structures can deflect
a low speed projectile. Any time a projectile enters a body
and does not have an exit wound, very careful exploration
of the projectile path is warranted. If the projectile is not
found along the expected path, clinically or radiographi-
cally, embolization of the projectile should be suspected.
When such an embolism does occur it usually involves
low speed projectiles [3,4]. Most cases involve arterial
embolization (70–75%) versus venous embolization
(25%) [5,6]. Antegrade and retrograde projectile migra-
tion within the arterial or venous vessels is possible [3].
Projectiles or fragments may enter the cardiovascular sys-
tem in one of four ways:
1) Directly into one of the cardiac chambers, where it
remains within the heart, or enters an outflow tract to the
lungs, or the arterial system. Paradoxical migration has
been described through a patent foramen ovale [6,20,21].
2) Directly into an artery, and then antegrade to the point
of entrapment depending on the projectile size and vessel
lumen [22].
3) Directly into a vein, where either antegrade or retro-
grade embolization is possible. This is dependant on
patient position, vessel and projectile size. Retrograde
venous embolization usually occurs in the very large veins
when the patient is in the upright position, or with cough-
ing, or a valsalva maneuver [3,4,6,22,23].
4) Erosion of the projectile through the pulmonary tissue
into a pulmonary vessel; and either to the pulmonary arte-
rial bed, or as in this case, into the pulmonary venous bed
with potential to become arterial.
In this case report the patient experienced an antegrade
venous embolization of a 410 slug. Up to 70% of patients
with venous projectile embolization remain hemody-
namically stable and may be asymptomatic [3]. In this
case there was also delayed migration of the projectile into
the left inferior pulmonary vein. Delayed migration of a
retained projectile and other complications such as: organ
infarction, septicemia, and thromboembolism has also
been demonstrated in up to 25% of patients [24]. The first
option for removal of an intravascular projectile embolus
is the use of interventional radiology [3]. If this is not fea-
sible, then surgery utilizing intraoperative fluoroscopy is
mandatory [3].
Even though the projectile may have eroded from the lung
base into a pulmonary vein that drains that segment, we
suspect the projectile was actually in the venous circula-
Repeat computerized tomography scan on readmission indi-cating the project l  may be in a cardiac chamber, imbedded in the cardiac muscle, or in a pulmon ry vein/pul onary v in bra ch (see arrow)Figure 3
Repeat computerized tomography scan on readmis-
sion indicating the projectile may be in a cardiac 
chamber, imbedded in the cardiac muscle, or in a 
pulmonary vein/pulmonary vein branch (see arrow).Page 3 of 4
(page number not for citation purposes)
Patient Safety in Surgery 2009, 3:12 http://www.pssjournal.com/content/3/1/12tion initially and its original location was misidentified. If
the projectile did erode into a pulmonary vein it would be
the first such occurrence ever reported.
We wish to emphasize to our colleagues that vigilance is
required in the hemodynamically stable, asymptomatic
patient with a retained projectile in the pulmonary bed
secondary to a gunshot wound who is discharged home
for follow up care and elective surgery. We suggest that
when a chest roentgenogram identifies a projectile/missile
in the pulmonary bed that CT scanning or angiography be
used to confirm its position. If the patient is symptomatic
then the projectile should be removed. In the operative
theatre transesophageal echocardiography will be of ben-
efit for location of the projectile and for following the
function of the heart. Intraoperative fluoroscopy may also
be of value. However, in this case palpation of the
involved pulmonary vein by the surgeon was the only
absolute way to identify the projectile's location. While
these missile emboli can be followed clinically in asymp-
tomatic patients, such management remains a point of
controversy [1,2,16,25,26].
Conclusion
Missile emboli that gain access to the pulmonary bed, and
eventually the heart, are a rare event. Patients that are
asymptomatic may be treated without surgery. Nonethe-
less, surgical intervention should be seriously considered
before releasing the patient from the hospital. A patient
exhibiting any symptoms will need an urgent/emergent
operative intervention.
Consent
Consent was received from the patient. A copy of the writ-
ten consent is available from the editor-in-chief of this
journal
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AMH provided the anesthesia for this case, as well as the
technical information about the case and aided in the
writing of the manuscript. RSC collected and compiled
the information, wrote and revised the manuscript. TJP
was the main technical adviser that wrote multiple revi-
sions of the manuscript and oversaw the submission of
this article. JJF provided detailed technical information
about cardiothoracic penetrating trauma and literature
information. TAS was the cardiothoracic surgeon of this
case who provided technical information and description
of the surgical procedure for this case. HE provided clini-
cal and technical radiographic guidance. All authors read
and approved the final manuscript.
References
1. Rich NM, Collins GJ, Andersen CA, McDonald PT, Kozloff L, Ricotta
JJ: Missile emboli.  J Trauma 1978, 18:236-239.
2. Ntlhe LM, Komati SM, Fourie PA, Rossouw AP: Missile embolism
– pulmonary vein to systemic bullet embolism: a case report
and review of the literature.  S Afr J Surg 2008, 46:58-60.
3. Bertoldo U, Enrichens F, Comba A, Ghiselli G, Vaccarisi S, Ferraris M:
Retrograde venous bullet embolism: a rare occurrence –
case report and literature review.  J Trauma 2004, 57:187-192.
4. Van Way CW III: Intrathoracic and intravascular migratory
foreign bodies.  Surg Clin North Am 1989, 69:125-133.
5. Rich NM, Collins GJ, Andersen CA: Missile emboli.  J Trauma 1978,
18:236-239.
6. Mattox KL, Beall AC, Ennix CL: Intravascular migratory bullets.
Am J Surg 1979, 137:192-195.
7. Mandal AK, Oparah SS: Unusually low mortality of penetrating
wounds of the chest.  J Thorac Cardiovasc Surg 1979, 77:162-168.
8. Bartlett H, Anderson CB, Steinhoff NG: Bullet embolism to the
heart.  J Trauma 1973, 13:476-479.
9. Symbas PN, Picone AL, Hatcher CR, Vlasis-Hale SE: Cardiac mis-
siles. A review of the literature and personal experience.  Ann
Surg 1990, 211:639-648.
10. Fisk RL, Addetia A, Gelfund GT, Brooks CHD, Dvorkin J: Missile
migration from lung to heart with delayed systemic emboli-
zation.  Chest 1977, 72:534-535.
11. Bilsker MS, Baurerlein EJ, Kammermann ML: Bullet embolus form
the heart to the right subclavian artery after gunshot wound
to the right chest.  Am Heart J 1996, 132:1093-1094.
12. Bland EF, Beebe GW: Missiles in the heart. A twenty-year fol-
low-up report of World War II cases.  N Engl J Med. 1966,
274(19):1039-1046.
13. Braun SD: Arterial embolization of a bullet.  AJR Am J Roentgenol
2003, 180:281.
14. Symbas PN, Symbas PJ: Missiles in the cardiovascular system.
Chest Surg Clin N Am 1997, 7:343-356.
15. Michelassi F, Pietrabissa A, Ferrari M, Mosca F, Vargish T, Moosa HH:
Bullet emboli to the systemic and venous circulation.  Surgery
1990, 107:239-245.
16. Symbas PN, Hatcher CR, Mansour KA: Projectile embolus of the
lung.  J Thorac Cardiovasc Surg 1968, 56:97-103.
17. Symbas PN, Harlaftis N: Bullet emboli in the pulmonary and sys-
temic arteries.  Ann Surg 1977, 185:318-320.
18. Fackler ML: Ballistic injury.  Ann Emerg Med 1986, 15:1451-1455.
19. Fackler ML: Gunshot wound review.  Ann Emerg Med 1996,
28:194-203.
20. Ledgerwood AM: The wandering bullet.  Surg Clin North Am 1977,
57:97-109.
21. Nazir Z, Esufali ST, Rao NS, Rizvi I: Venous bullet embolism: a
case report and review of the literature.  Injury 1992,
23:561-563.
22. Patel KR, Cortes LE, Semel L: Bullet embolism.  J Cardiovasc Surg
1989, 30:584-590.
23. Sclafani SJ, Mitchell WG: Retrograde venous bullet embolism.  J
Trauma 1981, 8:656-657.
24. Shannon FL, McCroskey BL, Moore EE: Venous bullet embolism:
rationale for mandatory extraction.  J Trauma 1987,
27:1118-1122.
25. Kortbeek JB, Clark JA, Carraway RL: Conservative management
of a pulmonary artery bullet embolism: case report and
review of the literature.  J Trauma 1992, 33:906-908.
26. Stephenson LW, Workman RB, Aldrete JS, Karp RB: Bullet emboli
to the pulmonary artery: a report of 2 patients and a review
of the literature.  Ann Thorac Surg 1976, 21:333-336.Page 4 of 4
(page number not for citation purposes)


Arterial embolization of a bullet.

Ballistic injury. Ann Emerg Med

Bullet embolism to the heart.

CA: Missile emboli.

EE: Venous bullet embolism: rationale for mandatory extraction.

Ennix CL: Intravascular migratory bullets.

Gunshot wound review. Ann Emerg Med

GW: Missiles in the heart. A twenty-year follow-up report of World War II cases.

Harlaftis N: Bullet emboli in the pulmonary and systemic arteries. Ann Surg

I: Venous bullet embolism: a case report and review of the literature. Injury

III: Intrathoracic and intravascular migratory foreign bodies. Surg Clin North Am

Missile migration from lung to heart with delayed systemic embolization. Chest

ML: Bullet embolus form the heart to the right subclavian artery after gunshot wound to the right chest. Am Heart J

Moosa HH: Bullet emboli to the systemic and venous circulation. Surgery

Oparah SS: Unusually low mortality of penetrating wounds of the chest. J Thorac Cardiovasc Surg

Projectile embolus of the lung. J Thorac Cardiovasc Surg

RB: Bullet emboli to the pulmonary artery: a report of 2 patients and a review of the literature. Ann Thorac Surg

Retrograde venous bullet embolism: a rare occurrence – case report and literature review.

RL: Conservative management of a pulmonary artery bullet embolism: case report and review of the literature.

Rossouw AP: Missile embolism – pulmonary vein to systemic bullet embolism: a case report and review of the literature.

Symbas PJ: Missiles in the cardiovascular system.

The wandering bullet. Surg Clin North Am

Vlasis-Hale SE: Cardiac missiles. A review of the literature and personal experience. Ann Surg

WG: Retrograde venous bullet embolism.

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Pulmonary bullet embolism – a safe treatment strategy of a potentially fatal injury: a case report

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