A Garzon

A Olsun

Bekim Ademi

C Trimble

CP Klein

F Abdo

JL Keeley

K Habdank

KK Nagy

KL Mattox

KR Patel

Luan Jaha

M Khalifeh

M Markovic

R Nguyen

RW Proudfoot

Tatjana Andreevska

TD Reil

V Bors

Vlora Ismaili-Jaha

Journal of Medical Case Reports

English

PubMed

Springer - Publisher Connector

CASE REPORT Open Access
Bullet embolization to the external iliac artery
after gunshot injury to the abdominal aorta:
a case report
Luan Jaha1*, Bekim Ademi1, Vlora Ismaili-Jaha2 and Tatjana Andreevska3
Abstract
Introduction: Abdominal vascular trauma is fairly common in modern civilian life and is a highly lethal injury.
However, if the projectile is small enough, if its energy is diminished when passing through the tissue and if the
arterial system is elastic enough, the entry wound into the artery may close without exsanguination and therefore
may not be fatal. A projectile captured may even travel downstream until it is arrested by the smaller distal
vasculature. The occurrence of this phenomenon is rare and was first described by Trimble in 1968.
Case presentation: Here we present a case of a 29-year-old Albanian man who, due to a gunshot injury to the
back, suffered fracture of his twelfth thoracic and first lumbar vertebra, injury to the posterior wall of his abdominal
aorta and then bullet embolism to his left external iliac artery. It is interesting that the signs of distal ischemia
developed several hours after the exploratory surgery, raising the possibility that the bullet migrated in the interim
or that there was a failure to recognize it during the exploratory surgery.
Conclusion: In all cases where there is a gunshot injury to the abdomen or chest without an exit wound and with
no projectile in the area, there should be a high index of suspicion for possible bullet embolism, particularly in the
presence of the distal ischemia.
Introduction
Abdominal vascular trauma is fairly common in modern
civilian life and is a highly lethal injury, with overall
mortality around 40% in some reported series. The main
cause for this high mortality relates to problems trans-
porting injured patients to the hospital fast enough to
prevent exsanguination. Furthermore, abdominal vascu-
lar injuries are rarely isolated, and other organs are
often severely damaged as well.
However, bullet penetration of the aorta is not always
fatal. If the projectile is small enough and the arterial
system elastic enough, the entry wound into the arterial
channel may close without exsanguination. A small pro-
jectile thus captured will travel within the lumen with
the current of blood flow until it is swept far enough to
be halted by the diminishing diameter of tile peripheral
vasculature. The occurrence of this phenomenon is rare.
In 1968, Trimble [1] was the first to summarize the
cases published until that time. There were 33 reports,
dating back to 1885. He added two additional cases.
Two more were added by Cyrus and Klein in 1972 [2],
and since then there have been several others [3-14]. In
these reports different techniques for treatment were
presented, starting with very common methods to ones
employing laparoscopic and endovascular techniques.
Here we present our experience with a gunshot injury
through the lumbar vertebra to the posterior wall of the
abdominal aorta, followed by bullet embolism to the left
external iliac artery.
Case report
Three hours after being shot in the back, a 29-year-old
Albanian man was admitted to the Surgical Department
of our Emergency Center. An examination revealed two
small caliber bullet holes over his thoracolumbar spine
and sacrum, paraplegia and absence of the pulses. The
deteriorating condition of our patient led to the decision
to surgically explore his abdomen. No injuries to the
* Correspondence: ljaha@yahoo.com
1Department of Vascular Surgery, University Clinical Center of Kosova, Rrethi i
Spitalit pn, 10000 Prishtina, Republic of Kosova
Full list of author information is available at the end of the article
Jaha et al. Journal of Medical Case Reports 2011, 5:354
http://www.jmedicalcasereports.com/content/5/1/354 JOURNAL OF MEDICAL
CASE REPORTS
© 2011 Jaha 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.
viscera were found. A small retroperitoneal hematoma
on his right side was opened. His pulse over his com-
mon iliac arteries was normal and there was no active
bleeding at the area. Drains were placed and his abdo-
men was closed in layers. Because of an insufficient
improvement of the monitored parameters, our patient
was intubated and transferred to our intensive care unit
for further resuscitation. Three hours later he developed
ischemia in his left leg. His leg was cold, with no pulse
up to the common femoral artery and there were signs
of discoloration. Computed tomography of his chest and
abdomen revealed two bullets - one in his left iliac fossa
and a second in front of his sacrum (Figure 1). Color
Doppler imaging revealed an obstruction of the external
iliac artery on his left side. No free fluid was found in
his abdomen. There was also a multiple fracture of his
twelfth thoracic and first lumbar vertebrae with no free
fluids in his abdomen (Figure 2). These findings alerted
the vascular surgery team and after a consultation, a
tentative diagnosis of a gunshot injury was made. The
decision was made to re-enter the abdomen.
A second surgery was performed eight hours after the
first one. At his left iliac fossa no significant hematoma
was noted. However, there was no pulse over his exter-
nal iliac artery. After the division of the surrounding tis-
sues it was possible to feel the obstructing foreign body
within the common iliac artery. Once vascular control
was obtained the artery was opened and the bullet
removed (Figure 3 and 4). The embolectomy of the dis-
tal arteries was performed using a Fogarty catheter and
a significant amount of thrombi was removed (Figure 5).
A pulse then returned to his leg. To alleviate developing
compartment syndrome, crural and femoral fasciotomy
were performed (Figure 6).
Although the leg performed well after the surgery, the
postoperative period was complicated by multiorgan fail-
ure, which resulted in the death of our patient eighth
days after receiving the injury.
Discussion
As previously stated, an elastic aorta is essential to avoid
fatal hemorrhage in patients with a gunshot wound to
the aorta. Trimble’s [1] collected series gathered from
the literature shows bullet embolization is three times
more frequent in the lower extremities than in the
upper extremities. The forces acting on a migrating
embolus to determine the direction of its movement are
the force of blood flow, gravity and position of the body.
Embolic projectiles that enter the left side of the aortic
arch or the abdominal aorta may be expected to be
found in a lower extremity. Those that enter the arterial
system through the left side of the heart or the right
side of the aortic arch may go to either an upper or
lower extremity. Emboli on the left side are more fre-
quent, as noted by Garzon and Gleidman [15] and by
Keeley [16]. The right and left common iliac arteries
Figure 1 CT scan of our patient with bullets.
Figure 2 Fracture of his twelfth thoracic vertebra.
Figure 3 Extraction of the bullet from the left common iliac
artery.
Jaha et al. Journal of Medical Case Reports 2011, 5:354
http://www.jmedicalcasereports.com/content/5/1/354
Page 2 of 4
arise from the bifurcation at different angles. The left
artery is 30° from the midline, more nearly a straight
continuation of the aorta than the right iliac which is
45° from the midline. Embolisms to the lower extremi-
ties are therefore three times more frequent on the left
side than on the right side. The importance of prompt
removal of the peripherally located projectile after
embolisms is generally stressed in the literature [15],
otherwise gangrene may develop. However, the develop-
ment of gangrene depends more on whether both
femoral arteries are occluded than on the length of time
itself [2,16]. Due to the absence of a proper diagnostic
evaluation at the first surgery we were not able to say if
the arterial obstruction occurred in the period between
the first and second surgery or was missed the first
time. In the case of the possibility of the obstruction
occurring between the operations, there are two scenar-
ios to consider. First, the migration of the projectile due
to the movement of the spine fragments over the incar-
cerated bullet. Transportation of our patient from “table
to table” may have facilitated detachment of the bullet
from his aortic wall and migration to his iliac artery and
resulted in a “secondary embolism”. If this was the case,
than this will be the first such event ever reported in
the literature. The second scenario implies the failure to
preoperatively and intra-operatively detect the bullet in
the iliac artery, and subsequent worsening of ischemia
after the first surgery due to the apposition thrombus
formation around the already incarcerated bullet in his
iliac artery. Regardless of the scenario, there is no doubt
that the massive compartment syndrome, developed due
to prolonged ischemia, significantly contributed to the
lethal outcome in our patient.
Conclusion
Not all gunshot injuries to the aorta are fatal. If the
energy of the projectile diminishes and the aortic wall is
elastic enough, the surrounding muscles will prevent
exsanguination. The projectile itself can act as an embo-
lus and travel through the vessels. The suspicion for this
should rise in all cases when there is a gunshot injury to
the abdomen or chest without an exit wound and with
no projectile in the area. Failure to recognize this is
associated with serious, often irreparable, damage to the
patient’s health and can even result in a lethal outcome.
Consent
Written informed consent was obtained from the
patient’s next of kin for publication of this case report
and any accompanying images. A copy of the written
consent is available for review by the Editor-in-Chief of
this journal.
Author details
1Department of Vascular Surgery, University Clinical Center of Kosova, Rrethi i
Spitalit pn, 10000 Prishtina, Republic of Kosova. 2Department of Pediatrics,
Figure 4 Extracted bullet.
Figure 5 Thrombectomized distal arteries.
Figure 6 Extensive crural and femoral fasciotomies.
Jaha et al. Journal of Medical Case Reports 2011, 5:354
http://www.jmedicalcasereports.com/content/5/1/354
Page 3 of 4
University Clinical Center of Kosova, Rrethi i Spitalit pn, 10000 Prishtina,
Republic of Kosova. 3Department of Thoracovascular Surgery, University “Kiril
and Metodij”, Skopje, Former Yugoslav Republic of Macedonia.
Authors’ contributions
JL and AB performed the surgery, and analyzed and interpreted the data. IJV
and AT reviewed the literature. All authors were major contributors to the
manuscript. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 25 July 2010 Accepted: 5 August 2011
Published: 5 August 2011
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doi:10.1186/1752-1947-5-354
Cite this article as: Jaha et al.: Bullet embolization to the external iliac
artery after gunshot injury to the abdominal aorta: a case report.
Journal of Medical Case Reports 2011 5:354.
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Bullet embolization to the external iliac artery after gunshot injury to the abdominal aorta: a case report

Crossref

Abi-Saad G: Penetrating missile embolisation. Eur J Vasc Surg

Arterial bullet embolism following thoracic gunshot wounds. Ann Surg

Bullet embolus to left femoral artery following thoracic gunshot wound. Thoracic Surg

Clauss RH: Bullet embolism. J Cardiovasc Surg (Torino)

Deneuville M: Gunshot wounds to the chest with arterial bullet embolization. Ann Vasc Surg

Ennix CL, DeBakey ME: Intravascular migratory bullets.

Gleidman ML: Peripheral embolization of bullet following perforation of thoracic aorta. Ann Surg

Gunshot wounds of the aorta with peripheral arterial bullet embolism.

H: Missile embolization revisited: a rationale for selective management. Am Surg

Pavie A: Bullet embolization from the left brachiocephalic vein to the right ventricle.

Putnik S: Rare forms of peripheral arterial embolism: review of 11 cases. Vascular

RL: Gunshot wound to the thorax with bullet embolization to the external carotid artery. J Thorac Imaging

S: Arterial bullet embolism.

Saad GA: Wandering intravascular missiles: report of five cases from the Lebanon war. Surgery

SS: Gunshot wound to the left ventricle with bullet embolization to the descending aorta: combined endovascular and surgical management.

Tosun R: Bullet embolism after gunshot injury: a case report. Heart Surg Forum

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Bullet embolization to the external iliac artery after gunshot injury to the abdominal aorta: a case report

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