Jonathan Fergus, MD MS
University of Chicago
Disclosure(s): No financial relationships to disclose
Bullet embolization is rare with estimates from combat settings ranging from 0.3%-1.1% of penetrating trauma. Although, surgical approaches are well documented, we advocate for endovascular retrieval with the support of a multidisciplinary team as the first-line approach.[1-3] Presented is a case of an intravenous bullet located at the IVC/RA junction.
Clinical Findings/Procedure Details:
A 39-year-old hemodynamically stable female presented with a single gunshot wound to the epigastrium. Initial CTA demonstrated an intraluminal bullet resting at the IVC/RA junction and a grade V liver laceration. Trauma surgery deferred open thoracotomy with ECMO due significant morbidity and mortality. IR recommended endovascular retrieval with right femoral vein cutdown with anesthesia.
A 9 Fr right IJ sheath was placed and a 7 Fr EN Snare was advanced to the IVC/RA junction to guard against central migration. A 5 Fr right femoral vein sheath was placed and venography was performed. The right femoral vein sheath was upsized to 26 Fr and two 7 Fr EN Snares were introduced with one deployed central to the bullet to add another layer of protection. The other snare secured and moved the bullet into the right femoral vein in anticipation for retrieval. The right IJ sheath/snare were exchanged for an IVC filter introducer sheath and an infrarenal IVC filter was placed. The patient was transported to the OR where the bullet was successfully retrieved via a right femoral vein cutdown.
Post-operative course included acute right iliac and femoral vein thrombosis complicated by compartment syndrome requiring three compartment fasciotomy. Therapeutic anticoagulation was initiated and two days later, repeat venogram demonstrated extensive thrombus from the right popliteal vein to the right common iliac vein. This was not amenable to mechanical thrombectomy due to friability of the primary right femoral vein closure. In addition to continued surgical management, repeat venogram 2 weeks later demonstrated persisting right lower extremity thrombus, poor inflow, and maturing collateral veins. Anticoagulation was continued and encouragingly, the patient’s fasciotomies were closed a month later. IR is currently monitoring for post thrombotic syndrome and will intervene if more aggressive therapy is required.
Conclusion and/or Teaching Points:
Intravenous bullet embolization is a rare, but well described phenomenon amenable to endovascular retrieval with multidisciplinary support.