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Surgical management of late bullet embolization from the abdomen to the right ventricle: Case report

Highlights • We present the case of a late bullet migration.• We describe our surgical approach for a bullet extraction.• We review the literature on the different treatment options in patients with bullet migration.


Introduction
Secondary embolus from gun projectile is a rare entity with few published cases in the literature. It represents a clinical and therapeutic dilemma because of the potential complications involving central and peripheral circulation, including pulmonary complications [1,2]. There have been reported less than 200 cases including embolization of other materials [3,4]. Clinical manifestations are associated with the anatomical site of embolism and mortality rate for a retained bullet is 6% associated with complication in 25% of cases. Mortality rate decreases to 1-2% if the bullet is removed [5]. We present a case of a retained and late bullet embolization, from the abdominal cavity to the right ventricle. Treated conservative initially and six years later after receiving a penetrating gunshot trauma, a sternotomy was performed. This patient was treated in a private practice hospital by a cardiothoracic surgeon.

Case report
A 33-year-old man with no personal, family or psychosocial history presented to the emergency department after receiving a gunshot wound on left flank with no evidence of any exit wounds. The patient had stable vital signs and no clinical data of abdominal tenderness at admission. Abdominal CT showed free intra-abdominal fluid and a gunshot bullet on the pelvic cavity medial to the iliopsoas muscle, the chest x-ray showed no abnormalities ( Fig. 1). An exploratory laparotomy was performed finding 2500 ml of blood in the abdomen. A grade I and III vascular lesions were found in the jejunum mesentery and left iliac vein respectively; and a grade II intestinal lesion in the distal sigmoid. All the lesions were repaired and the gunshot bullet was not extracted because of hemodynamic instability at the moment. At that time,  the patient was treated by a general surgeon in a private practice hospital.
The patient presents 6 years later with non-productive cough and retrosternal pain with no other symptoms. Physical exploration was non-remarkable. A chest x-ray and thoracoabdominal CT showed a radiopaque artefact on the ventricular floor. An EKG, transthoracic echocardiogram and cardiac catheterization were performed showing no disruptions or alterations in the cardiac anatomy and physiology (Fig. 2).  Because of the high risk for pulmonary embolization, surgical exploration was planned. An sternotomy was performed by a cardiothoracic surgeon, the patient was submitted to extracorporeal circulation, the projectile was identified in the ventricular septum and it was extracted through an incision in the right atrium without presenting any complication associated to the procedure. The projectile measured 20 × 10 mm (Fig. 3).
The patient had complete recovery from surgery and didn't need ventilatorey or dynamic support during its course. He was discharged 6 days after surgery with full resolution of the symptoms and without any complication. Six-month follow up at the clinic was uneventful.

Discussion
In 1834, Thomas David reported for the first time a woodfragment embolization from the venous circulation to the right ventricle in a 10-year-old male patient [1,2]. There have been multiple reports from foreign bodies that migrate to the pulmonary artery or the right ventricle like hypodermic needles, intravenous catheters, bone fragments, and bullets [3]. There have been reported less than 200 cases including embolization of other materials; most of the gunshot bullet embolization cases reported on literature were reported after war. A revision during Vietnam war reported a 0.3% incidence [1,2,4]. Foreign bodies can enter venous system through a direct protrusion into the lumen or by a slower erosion of the vascular wall and can be presented up to 14 years later [1,10].
Clinical manifestations are associated with the anatomical site of embolism, arterial embolization is presented as ischemic distal disease while venous embolization is symptomatic in 70% of cases, generally associated with occupation on left ventricle and pulmonary artery [2,4,6]. Imaging studies are primordial for diagnosis confirmation. X-rays from the site the projectile first impacted and the finding of it in another body cavity raises the suspicious for diagnosis [4]. Some authors recommend CT, transthoracic or transesophagic ecocardiogram and cardiac catheterism even though there is no consensus for an algorithm for diagnostic approach [7][8][9].
The mortality rate for a retained bullet is 6% associated with complication in 25% of cases. Mortality rate decreases to 1-2% if the bullet is removed [5]. Other authors suggest it should be removed only in patients that are symptomatic, with a size less than 5 mm, irregular structure,proximal to an artery, located at left cardiac cavities and those creating electrocardiographic, hemodynamic or systemic alterations [11,12]. A 40-case series reported after second world war with follow up to 20 years, showed 25% incidence of pericarditis with conservative management and observation. One case developed left-ventricle hypertrophia secondary to aortic valve lesion [13]. There are follow up cases with conservative management in which there was pulmonary artery embolization with no complications reported [14]. Another alternative for management is endovascular treatment, which is an option in those hemodynamically stable patients with gunshot embolization to the pulmonary artery, intraarterial or any of the cardiac chambers [2,15].

Conclusion
Even though an algorithm of treatment does not exist for this pathology, each patient should be individualized. Invasive treatment should be avoided unless necessary; each clinical scenario should be analyzed by an expert team to propose the best therapeutic approach for the patient. The present paper follows the guidelines of the SCARE criteria [16] for publication.

Conflicts of interest
Nothing to declare.

Funding
Nothing to declare.

Ethical approval
Ethical approval was given to publish this case report.

Consent
Consent was obtained to publish this case report.

Author contribution
Alan Ramos Mayo, MD-study concept, writing paper, data collection.
Jose Antonio Diaz Elizondo, MD-study concept, writing paper, approval of final manuscript.
Francisco Xavier Treviño Garza, MD-study concept, approval of final manuscript.

Registration of research studies
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Guarantor
The corresponding author and co-authors accept full responsibility for the work.