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Penetrating missile embolisation
Eur J Vasc Surg 7, 467469 (1993)
CASE R E P O R T
Penetrating Missile Embolisation Moharnmad Khalifeh, Ghattas Khoury, Hani Hajj, Roger Sfeir, Samar Khoury and George Abi-Saad Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon The present case report is that of a 13-year-old boy, who was admitted to the Emergency Unit at the American University of Beirut Medical Center (AUBMC), with a bullet injury to the right upper quadrant with no exit. Chest X-ray and KUB failed to reveal the bullet and there was no evidence of haemo- or pneumothorax. X~ray of both thighs showed the bullet at the level of the right groin. The bullet penetrated the liver, diaphragm and pericardium. It entered through the left ventricle and embolised through the arterial circulation to the right superficialfemoral artery. Included in this report is a review and analysis of patients with missile embolisation, who were treated at the AUBMC over the last 10 years. Key Words: Missile embolisation; Injury; Vessels.
Case Report A 13-year-old boy was brought to the Emergency Unit 20 min after a bullet injury to his abdomen. His previous medical history was negative except for an exploratory laparotomy which was performed in our hospital 2 years previously, again because of a bullet injury to the abdomen. In the Emergency Unit the boy was in hypovolaemic shock; his vital signs revealed a systolic blood pressure below 50 mmHg, pulse 160 b p m and a spontaneous respiratory rate of 25 breaths per minute. Physical examination showed an entry site 1.5 cm in diameter in the right upper quadrant with no exit. The abdomen was soft with normal bowel sounds but localised tenderness was present at the site of entry. Both lung fields were clear on auscultation and the heart was beating regularly. Both femoral pulses were present but weak and the patient was moving both lower extremities with no ischaemic changes. Resuscitation was started immediately upon arrival using lactated Ringer's solution and haemaccel through two large bore central and peripheral intravenous cannulae. Chest X-ray was negative with no evidence of haemo- or pneumothorax and normal cardiac silhouette. Plain X-rays of the abdomen and Please address requests for reprints: Dr Ghattas Khoury, Department of Surgery, American University of Beirut Medical Center, P.O. Box 113-6044, Beirut, Lebanon. 0950-821X/93/070467+~03$08.00/0© 1993Grune & Stratton Ltd.
pelvis failed to show a bullet. Bullet embolisation was suspected and X-ray of both thighs showed the bullet in the right groin area (Fig. 1). Blood was typed and cross-matched and the patient was taken to the operating theatre. On arrival his systolic BP was 70 mmHg, pulse 90/min and he was breathing spontaneously. Pre-oxygenation was started and anaesthesia was induced with ketamine HC1 100 mg intravenously (i.v.) and scoline to facilitate intubation. Anaesthesia was maintained with nitrous oxide and incremental doses of alloferin/ pavulon and fentanyl were given according to need. The abdomen was explored through a midline incision from xiphoid to pubis. The bullet was found to have shattered the right hepatic lobe, exiting from the dome of the left hepatic lobe, penetrating the diaphragm and entering the pericardium, from which blood was gushing. A decision was taken immediately to extend the incision into the chest and a median sternotomy was performed in continuity with the midline abdominal incision. The pericardium was opened and an actively bleeding perforation of the left ventricle was identified, admitting the index finger. This was sutured immediately using pledgeted 3-0 tavdec sutures. The liver laceration was debrided and sutured, the diaphragmatic injury closed and bleeding controlled. The rest of the laparotomy was negative. A right groin incision was performed. The right
468
M. Khalifeh et al.
adequate. Serial arterial blood gases (ABGs) were taken and acidosis corrected using sodium bicarbonate. The patient was extubated before transfer to the recovery room and had an uneventful postoperative course.
Discussion
Fig. 1. X-rayof the pelvis and upper thighs revealingthe bullet in the right groin. common femoral and superficial femoral arteries were identified and the bullet was located in the right superficial femoral artery. After achieving proximal and distal control a transverse arteriotomy was performed and the bullet extracted (Fig. 2). The procedure lasted about three hours and the patient received 6 units of whole fresh blood and 2 units of haemaccell. Urine output was monitored and was
Fig. 2. Extractionof the bullet from the femoralartery. Eur J VascSurg Vol 7, July 1993
Bullet embolisation into the systemic or pulmonary circulation following a penetrating w o u n d is an infrequent occurrence. The first description of embolism of a foreign body was a peripheral vein to the heart was described by Davis in 1834.1 Since that time, approximately 150 cases of intravascular migration have been described. 2'3'4 Only 30 cases dealing with peripheral arterial missile emboli have been reported in the literature over the past 22 years. 5 In the last 10 years, seven patients with missile embolisation have been treated at the American University of Beirut Medical Centre. 2'6 In five the missile entered the heart or thoracic aorta with peripheral embolisation and in two via the internal carotid artery and interior vena cava (IVC) with embolisation into the middle cerebral artery and heart respectively (Table 1). Among the factors affecting missile embolisation are the missile's calibre and its kinetic energy, gravity, anatomy of the vessels and the force of blood flow. Small calibre bullets usually have a low kinetic energy and therefore produce minimal local tissue loss and are usually unable to enter the heart or circulation. Entrance of a missile into the arterial circulation results from penetration of either the aorta, the left side of the heart, pulmonary vein, right atrium with presence of atrial septal defect or patent foramen ovale (paradoxical embolism). Entrance into the venous circulation results from penetration of either a peripheral vein, the vena cava, the right side of the heart or a pulmonary artery. 7 Retrograde venous embolisation from the superior vena cava or IVC against flow has been reported. The diagnosis of bullet embolisation should be suspected w h e n there is an association between two entities: the absence of an exit and whenever the outline plain X-ray does not show the missile in the area of injury but at a distant location. In haemodynamically stable patients, arterial or venous angiography and echocardiography should be performed to confirm the diagnosis which is already suspected after the initial plain X-rays. Operative management should take into con-
Penetrating Missile Embolisation
469
Table 1. Missile embolization at AUBMC 1980-1990 Age (years)
Missile
Site of entry
Site of embolism
Diagnosis
Treatment
Results
15
Bullet
IVC
R. Ventricle
CXR, Echo
Conservative
Good
16
Bullet
Chest
R. Iliac Artery
CXR, DSA
Amputation
Death
13
Shrapnel
Chest
R. Common Femoral Artery
DSA
Embolectomy
Good
45
Shrapnel
Thoracic Aorta
R. Common Femoral Artery
CXR, DSA
Embolectomy
Good
32
Shrapnel
L. Atrium
L. Common Iliac Artery
X-ray of Pelvis
Suturing of Left Atrium, Embolectomy
Good
40
Bullet
L. Ventricle
R. Common Iliac Artery
X-ray of Pelvis
Thoracotomy
Death
18
Bullet
R. Internal Carotid Artery
Middle Cerebral Artery
Angiography
Conservative
Good
sideration multiple factors. In patients w h o are not haemodynamically stable, despite adequate fluid and blood replacement, surgery should address the entry site whether by thoracotomy or laparotomy to control bleeding. The site of the embolus can be dealt with later. In patients w h o are haemodynamically stable one can avoid thoracotomy, especially if aortography and/or echocardiography are not significantly abnormal and surgery should be directed to the site of the embolus and the missile removed via a transverse arteriotomy to avoid limb ischaemia. Laparotomy is mandatory when the entry site is the abdominal wall. There is a three-fold incidence in the literature of left limb embolisation in comparison to the right. The explanation may be related to the aortic bifurcation where the right iliac vessels form an agle of 45 ° compared with 30 ° on the left.
References 1 MATTOX KL, BEAL AC, ENNIX CL, DEBAKE¥ ME. Intravascular migratory bullets. Am J Surg 1979; 137: 192-195. 2 ABDO F, MASSAD M, SLIM M, SABA M, NAJJAR F, ABI SAAD G. Wandering intravascular missiles: report of five cases from the Lebanon war. Surgery 1988; 103: 376-379. 3 TRIMBLEC. Arterial bullet embolism following thoracic gun shot wounds. Ann Surg 1968; 103: 911-915. 4 GARZON A, GLEIDMAN ML. Peripheral embolization of a bullet following perforation of the thoracic aorta. Ann Surg 1964; 160: 901-904. 5 SHANON JJ, Vo NM, STANTON PE, DIMLER M. Peripheral arterial missile emoblization. J Vasc Surg 1987; 5: 773-778. 6 KHOURY GS. Penetrating trauma to the vascular tree. Curr Prac Surg 1993; 5: 38-47. 7 SYMBASPN, VLASIS-HALE SE, PICONE AL, HATCHER CR. Missiles in the heart. Ann Thorac Surg 1989; 48: 192-194.
Accepted 1 November 1991
Eur ] Vasc Surg Vol 7, July 1993
CASE R E P O R T
Penetrating Missile Embolisation Moharnmad Khalifeh, Ghattas Khoury, Hani Hajj, Roger Sfeir, Samar Khoury and George Abi-Saad Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon The present case report is that of a 13-year-old boy, who was admitted to the Emergency Unit at the American University of Beirut Medical Center (AUBMC), with a bullet injury to the right upper quadrant with no exit. Chest X-ray and KUB failed to reveal the bullet and there was no evidence of haemo- or pneumothorax. X~ray of both thighs showed the bullet at the level of the right groin. The bullet penetrated the liver, diaphragm and pericardium. It entered through the left ventricle and embolised through the arterial circulation to the right superficialfemoral artery. Included in this report is a review and analysis of patients with missile embolisation, who were treated at the AUBMC over the last 10 years. Key Words: Missile embolisation; Injury; Vessels.
Case Report A 13-year-old boy was brought to the Emergency Unit 20 min after a bullet injury to his abdomen. His previous medical history was negative except for an exploratory laparotomy which was performed in our hospital 2 years previously, again because of a bullet injury to the abdomen. In the Emergency Unit the boy was in hypovolaemic shock; his vital signs revealed a systolic blood pressure below 50 mmHg, pulse 160 b p m and a spontaneous respiratory rate of 25 breaths per minute. Physical examination showed an entry site 1.5 cm in diameter in the right upper quadrant with no exit. The abdomen was soft with normal bowel sounds but localised tenderness was present at the site of entry. Both lung fields were clear on auscultation and the heart was beating regularly. Both femoral pulses were present but weak and the patient was moving both lower extremities with no ischaemic changes. Resuscitation was started immediately upon arrival using lactated Ringer's solution and haemaccel through two large bore central and peripheral intravenous cannulae. Chest X-ray was negative with no evidence of haemo- or pneumothorax and normal cardiac silhouette. Plain X-rays of the abdomen and Please address requests for reprints: Dr Ghattas Khoury, Department of Surgery, American University of Beirut Medical Center, P.O. Box 113-6044, Beirut, Lebanon. 0950-821X/93/070467+~03$08.00/0© 1993Grune & Stratton Ltd.
pelvis failed to show a bullet. Bullet embolisation was suspected and X-ray of both thighs showed the bullet in the right groin area (Fig. 1). Blood was typed and cross-matched and the patient was taken to the operating theatre. On arrival his systolic BP was 70 mmHg, pulse 90/min and he was breathing spontaneously. Pre-oxygenation was started and anaesthesia was induced with ketamine HC1 100 mg intravenously (i.v.) and scoline to facilitate intubation. Anaesthesia was maintained with nitrous oxide and incremental doses of alloferin/ pavulon and fentanyl were given according to need. The abdomen was explored through a midline incision from xiphoid to pubis. The bullet was found to have shattered the right hepatic lobe, exiting from the dome of the left hepatic lobe, penetrating the diaphragm and entering the pericardium, from which blood was gushing. A decision was taken immediately to extend the incision into the chest and a median sternotomy was performed in continuity with the midline abdominal incision. The pericardium was opened and an actively bleeding perforation of the left ventricle was identified, admitting the index finger. This was sutured immediately using pledgeted 3-0 tavdec sutures. The liver laceration was debrided and sutured, the diaphragmatic injury closed and bleeding controlled. The rest of the laparotomy was negative. A right groin incision was performed. The right
468
M. Khalifeh et al.
adequate. Serial arterial blood gases (ABGs) were taken and acidosis corrected using sodium bicarbonate. The patient was extubated before transfer to the recovery room and had an uneventful postoperative course.
Discussion
Fig. 1. X-rayof the pelvis and upper thighs revealingthe bullet in the right groin. common femoral and superficial femoral arteries were identified and the bullet was located in the right superficial femoral artery. After achieving proximal and distal control a transverse arteriotomy was performed and the bullet extracted (Fig. 2). The procedure lasted about three hours and the patient received 6 units of whole fresh blood and 2 units of haemaccell. Urine output was monitored and was
Fig. 2. Extractionof the bullet from the femoralartery. Eur J VascSurg Vol 7, July 1993
Bullet embolisation into the systemic or pulmonary circulation following a penetrating w o u n d is an infrequent occurrence. The first description of embolism of a foreign body was a peripheral vein to the heart was described by Davis in 1834.1 Since that time, approximately 150 cases of intravascular migration have been described. 2'3'4 Only 30 cases dealing with peripheral arterial missile emboli have been reported in the literature over the past 22 years. 5 In the last 10 years, seven patients with missile embolisation have been treated at the American University of Beirut Medical Centre. 2'6 In five the missile entered the heart or thoracic aorta with peripheral embolisation and in two via the internal carotid artery and interior vena cava (IVC) with embolisation into the middle cerebral artery and heart respectively (Table 1). Among the factors affecting missile embolisation are the missile's calibre and its kinetic energy, gravity, anatomy of the vessels and the force of blood flow. Small calibre bullets usually have a low kinetic energy and therefore produce minimal local tissue loss and are usually unable to enter the heart or circulation. Entrance of a missile into the arterial circulation results from penetration of either the aorta, the left side of the heart, pulmonary vein, right atrium with presence of atrial septal defect or patent foramen ovale (paradoxical embolism). Entrance into the venous circulation results from penetration of either a peripheral vein, the vena cava, the right side of the heart or a pulmonary artery. 7 Retrograde venous embolisation from the superior vena cava or IVC against flow has been reported. The diagnosis of bullet embolisation should be suspected w h e n there is an association between two entities: the absence of an exit and whenever the outline plain X-ray does not show the missile in the area of injury but at a distant location. In haemodynamically stable patients, arterial or venous angiography and echocardiography should be performed to confirm the diagnosis which is already suspected after the initial plain X-rays. Operative management should take into con-
Penetrating Missile Embolisation
469
Table 1. Missile embolization at AUBMC 1980-1990 Age (years)
Missile
Site of entry
Site of embolism
Diagnosis
Treatment
Results
15
Bullet
IVC
R. Ventricle
CXR, Echo
Conservative
Good
16
Bullet
Chest
R. Iliac Artery
CXR, DSA
Amputation
Death
13
Shrapnel
Chest
R. Common Femoral Artery
DSA
Embolectomy
Good
45
Shrapnel
Thoracic Aorta
R. Common Femoral Artery
CXR, DSA
Embolectomy
Good
32
Shrapnel
L. Atrium
L. Common Iliac Artery
X-ray of Pelvis
Suturing of Left Atrium, Embolectomy
Good
40
Bullet
L. Ventricle
R. Common Iliac Artery
X-ray of Pelvis
Thoracotomy
Death
18
Bullet
R. Internal Carotid Artery
Middle Cerebral Artery
Angiography
Conservative
Good
sideration multiple factors. In patients w h o are not haemodynamically stable, despite adequate fluid and blood replacement, surgery should address the entry site whether by thoracotomy or laparotomy to control bleeding. The site of the embolus can be dealt with later. In patients w h o are haemodynamically stable one can avoid thoracotomy, especially if aortography and/or echocardiography are not significantly abnormal and surgery should be directed to the site of the embolus and the missile removed via a transverse arteriotomy to avoid limb ischaemia. Laparotomy is mandatory when the entry site is the abdominal wall. There is a three-fold incidence in the literature of left limb embolisation in comparison to the right. The explanation may be related to the aortic bifurcation where the right iliac vessels form an agle of 45 ° compared with 30 ° on the left.
References 1 MATTOX KL, BEAL AC, ENNIX CL, DEBAKE¥ ME. Intravascular migratory bullets. Am J Surg 1979; 137: 192-195. 2 ABDO F, MASSAD M, SLIM M, SABA M, NAJJAR F, ABI SAAD G. Wandering intravascular missiles: report of five cases from the Lebanon war. Surgery 1988; 103: 376-379. 3 TRIMBLEC. Arterial bullet embolism following thoracic gun shot wounds. Ann Surg 1968; 103: 911-915. 4 GARZON A, GLEIDMAN ML. Peripheral embolization of a bullet following perforation of the thoracic aorta. Ann Surg 1964; 160: 901-904. 5 SHANON JJ, Vo NM, STANTON PE, DIMLER M. Peripheral arterial missile emoblization. J Vasc Surg 1987; 5: 773-778. 6 KHOURY GS. Penetrating trauma to the vascular tree. Curr Prac Surg 1993; 5: 38-47. 7 SYMBASPN, VLASIS-HALE SE, PICONE AL, HATCHER CR. Missiles in the heart. Ann Thorac Surg 1989; 48: 192-194.
Accepted 1 November 1991
Eur ] Vasc Surg Vol 7, July 1993