Injury, Int. J. Care Injured 46 (2015) 166–168
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Endovascular management of an intracardiac bullet Mahyar Ghanaat *, Charles Goldenberg, James Walsh, Salvatore J. Sclafani SUNY Downstate Medical Center, Department of Interventional Radiology, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 July 2014
Intravascular bullets may cause diagnostic and management difficulties. We describe a bullet overlying the cardiac silhouette on X-ray which was identified to be at the cavoatrial junction on cavography. The bullet was removed via endovascular techniques utilizing occlusion balloon and reverse trendelenberg position. Published by Elsevier Ltd.
Keywords: Intracardiac bullet Intravascular bullet Intravenous bullet Embolectomy Extraction Occlusive-balloon Interventional radiology Management
Case A 24-year-old man with multiple gunshot wounds to the upper and lower extremities was brought in by EMS to our level I trauma centre. A right axillary entry wounds was seen with no exit wounds. Patient was taken to the operative room as he was deemed unstable for imaging. Exploratory laporotomy was negative. A right sided chest tube was inserted in the operating room and drained 200 mL of bloody fluid. Intraoperative chest Xray demonstrated a bullet overlying the cardiac silhouette (Fig. 1). Patient was then taken to CT. CT chest demonstrated a bullet in the region of the cavoatrial junction which could not be accurately delineated due to streak artefact (Fig. 2). No active extravasation of contrast was seen. Patient was then taken to the angiography suite for further evaluation. Patient presented with a right femoral vein sheath for blood product infusion. A left femoral vein access was obtained under standard fashion and a cavogram was performed which showed that the bullet to be within the right atrium (Fig. 3). Gentle probing of the bullet region resulted in movement of the bullet by the catheter in the right atrium confirming the intracardiac location of the bullet. The angiography table was then rotated immediately into a 408 upright position (reverse Trendelenburg) to inhibit cephalad migration towards the right ventricle.
* Corresponding author at: Department of Radiology, 450 Clarkson Avenue, Brooklyn, New York 11230, United States. Tel.: +1 718 270 1603. E-mail address: [email protected] (M. Ghanaat). http://dx.doi.org/10.1016/j.injury.2014.07.018 0020–1383/Published by Elsevier Ltd.
Bullet extraction was then performed. A 5 French sheath was exchanged over sequential dilatation for a 14 French long sheath. Through this sheath, a 7 French catheter with a compliant 27 mm occlusion balloon was advanced gently over a guidewire into the right atrium, cephalad to the bullet. The balloon was inflated. The catheter was then pulled down until it moved the bullet. The bullet was then dragged caudad to the balloon through the cavoatrial junction into the inferior vena cava. Continued extraction was performed until the bullet fell into the right renal vein. A second venous catheter was placed via existing right femoral sheath. Through that catheter a six wire basket was advanced into the right renal vein and used to trap the bullet. As the bullet was pulled out of the renal vein, it became dislodged from the basket in the IVC. However the occlusion balloon had been pulled downward as well so the bullet did not go back into the renal vein. Extraction proceeded until the bullet reached the pelvic brim, where it fell by gravity into the right internal iliac vein. Extraction from this vein was not deemed feasible give patient’s condition. Attempts to push the bullet further into that vein were unsuccessful and the orifice of this vein could not be engaged. A 14 mm 4 cm nitinol bare metal stent was placed at the junction of the common and external iliac veins, covering the orifice of the internal iliac vein. This trapped the bullet to prevent remigration (Fig. 4). Thrombus was aspirated from the sheaths. Left femoral sheath was then removed with hemostasis achieved by manual compression. Subsequent hospital course was complicated by pulmonary embolism. The patient was discharged 23 days after admission.
M. Ghanaat et al. / Injury, Int. J. Care Injured 46 (2015) 166–168
167
Fig. 1. Portable intraoperative radiograph demonstrates bullet overlying the cardiac silhouette. Fig. 4. Metal stent at the junction of the common and external iliac veins, covering the orifice of the internal iliac vein to prevent remigration. Note occlusive balloon within distal inferior vena cava.
Fig. 2. Chest CT demonstrates bullet in the cavoatrial region.
Discussion Until the mid-20th century, most patients with intracardiac or intravascular bullets died [3]. With advances in medicine and cardiothoracic surgery, retrieval of intracardiac bullets became an
Fig. 3. Digital subtraction venography demonstrates bullet in the right atrium. ‘‘Blurry bullet’’ sign is noted.
option with or without bypass and surgery was usually recommended [3–5]. Since their invention in 1964 by Dotter, percutaneous interventional procedures have become an important and reliable method of bullet retrieval [1,6,7]. Galante and London [4] proposed that in stable patients, left sided intracardiac bullets may be managed surgically, whereas those in the right heart may be managed percutaneously. Intravascular and intracardiac bullets are a diagnostic and therapeutic challenge. The portable chest X-ray may only reveal a bullet in the area of the cardiac silhouette without clear spacial resolution. The ‘‘blurry bullet’’ sign may be present on the radiograph secondary to cardiac motion. This was observed during venography (Fig. 3) and fluoroscopy (Video 1). CT scans, although helpful, are often accompanied by beam hardening artefact that limits detailed localization (Fig. 2). Some have suggested that the use of ultrasound, transthoracic echocardiography, or transesophageal echocardiography may aid in diagnosis and localization [8–10]. However, an arteriogram or a venogram is often necessary to discern the exact position of the bullet [11]. Management should be performed emergently after patient stabilization due to various complications. Intravenous bullets in the iliac vein, renal vein, and hepatic vein have been reported to migrate to or from the IVC [2,8,12]. Such bullets can easily migrate to the right atrium, right ventricle, and the pulmonary vasculature [2]. They may also cause damage to the chordae tendineae or cause arrhythmia. Intaarterial bullets have been reported to cause adverse effects such as limb, cerebral, and ocular ischaemia [4,8,13]. We put the patient in reverse Trendelenburg position to decrease the likelihood of cephalad migration. Although retrieval of a bullet solely with the use of a snare instrument has been performed in the past with ‘‘relative ease’’ [6], a more comprehensive approach involves the use of an occlusion balloon to prevent central migration [1,2,7,14]. Depending on its shape, a bullet may easily escape a snare or a basket instrument. However, an occlusion balloon may have two minor disadvantages. It creates stasis which predisposes to clotting and also creates blockage of flow creating a high pressure system distally. The interventionalist should work swiftly and hold the balloon at all times to prevent its movement from the high flow system. In this
168
M. Ghanaat et al. / Injury, Int. J. Care Injured 46 (2015) 166–168
case, it is likely that the patient’s pulmonary embolism may have been secondary IVC thrombus formed during the procudure. Different methods have been used to stabilize a migratory bullet in the femoral vein such as a balloon catheter sutured to the skin and a retrieval basket [1,2]. A surgical venotomy is often used to retrieve the bullet from the femoral vein which is relatively superficial. Some interventionalists have also retrieved a bullet via the femoral vein using a small groin incision [7] or using a 24-F split renal Amplatz dilator [14]. In this case, the bullet fell by gravity into a nonessential blood vessel and a stent was placed to cage it and avoid remigration as the patient was unstable. In general, bullets in tissue need not be removed unless they impinge on vital structures or can easily be accessed [15]. Inconsequential chronically retained intracardiac bullet has been reported at autopsy [16]. Lead bullets can lead to lead toxicity due to resorption when left in contact with synovial or intracerebral fluid [17], and to arthropathy when left in joints [15]. Although intravascular bullets are not known to cause lead toxicity, they may serve as thrombogenic foci, which also favours removal in possible.
Conclusion Intravenous and right sided intracardiac bullets may safely be managed via interventional methods using an occlusion balloon, snare, and/or a basket. Patients with suspected intravenous bullets should preferably be placed in reverse Trendelenburg position both during the procedure and also during transfer to decrease the likelihood of central migration. Although venotomy may be used to remove a bullet trapped in the common femoral vein, a stent in the common/external iliac veins can effectively prevent the central migration of a bullet in the internal iliac vein.
Conflict of interest The authors report no conflicts of interest related to this case report.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.injury.2014.07.018.
References [1] Sclafani SJ, Mitchell WG. Retrograde venous bullet embolism. J Trauma 1981;21(August (8)):656–7. [2] Sclafani SJ, Shatzkes D, Scalea T. The removal of intravascular bullets by interventional radiology: the prevention of central migration by balloon occlusion – case report. J Trauma 1991;31(October (10)):1423–5. [3] Flick Jr JB. Right ventriculotomy for removal of intracardiac bullet. Ann Surg 1960;151(February (2)):231–4. [4] Galante J, London JA. Left ventricular bullet embolus: a case report and review of the literature. J Emerg Med 2010;39(July (1)). [5] Graham JM, Mattox KL. Right ventricular bullet embolectomy without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1981;82(August (2)):310–3. [6] Nosher JL, Siegel R. Percutaneous retrieval of nonvascular foreign bodies. Radiology 1993;187(June (3)):649–51. [7] Ronsivalle J, Statler J, Venbrux AC, Arepally A. Intravascular bullet migration: a report of two cases. Mil Med 2005;170(December (12)):1044–7. [8] Bonk RT, Harrison SD, Meissner MH. Intravascular bullet localization by sonography. AJR Am J Roentgenol 1996;167(July (1)):152. [9] LiMandri G, Gorenstein LA, Starr JP, Homma S, Auteri J, Gopal AS. Use of transesophageal echocardiography in the detection and consequences of an intracardiac bullet. Am J Emerg Med 1994;12(January (1)):105–6. [10] Hashimi MW, Jenkins DR, McGwier BW, Massey CV, Alpert MA. Comparative efficacy of transthoracic and transesophageal echocardiography in detection of an intracardiac bullet fragment. Chest 1994;106(July (1)):299–300. [11] Abad J, Merino MJ, Alted E. Case report: wandering intravascular bullet with aortic pseudoaneurysm. Clin Radiol 1993;47(May (5)):355–6. [12] Mattox KL, Beall Jr AC, Ennix CL, DeBakey ME. Intravascular migratory bullets. Am J Surg 1979;137(February (2)):192–5. [13] Pacio CI, Murphy MA. B.B. Embolus causing monocular blindness in a 9-yearold boy. Am J Ophthalmol 2002;134(November (5)):776–8. [14] Gaylord GM, Johnsrude IS. Split 24-F amplatz dilator for percutaneous extraction of an intravascular bullet: case report and technical note. Radiology 1989;170(March (3 Pt. 1)):888–9. [15] Sclafani SJ, Vuletin JC, Twersky J. Lead arthropathy: arthritis caused by retained intra-articular bullets. Radiology 1985;156(August (2)): 299–302. [16] Springer J, Newman W, McGoey R. Intravascular bullet embolism to the right atrium. J Forensic Sci Jan 2011;56(January (Suppl. 1)):S259–62. [17] Coon T, Miller M, Shirazi F, Sullivan J. Lead toxicity in a 14-year-old female with retained bullet fragments. Pediatrics 2006;117(January (1)):227–30.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Endovascular management of an intracardiac bullet Mahyar Ghanaat *, Charles Goldenberg, James Walsh, Salvatore J. Sclafani SUNY Downstate Medical Center, Department of Interventional Radiology, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 July 2014
Intravascular bullets may cause diagnostic and management difficulties. We describe a bullet overlying the cardiac silhouette on X-ray which was identified to be at the cavoatrial junction on cavography. The bullet was removed via endovascular techniques utilizing occlusion balloon and reverse trendelenberg position. Published by Elsevier Ltd.
Keywords: Intracardiac bullet Intravascular bullet Intravenous bullet Embolectomy Extraction Occlusive-balloon Interventional radiology Management
Case A 24-year-old man with multiple gunshot wounds to the upper and lower extremities was brought in by EMS to our level I trauma centre. A right axillary entry wounds was seen with no exit wounds. Patient was taken to the operative room as he was deemed unstable for imaging. Exploratory laporotomy was negative. A right sided chest tube was inserted in the operating room and drained 200 mL of bloody fluid. Intraoperative chest Xray demonstrated a bullet overlying the cardiac silhouette (Fig. 1). Patient was then taken to CT. CT chest demonstrated a bullet in the region of the cavoatrial junction which could not be accurately delineated due to streak artefact (Fig. 2). No active extravasation of contrast was seen. Patient was then taken to the angiography suite for further evaluation. Patient presented with a right femoral vein sheath for blood product infusion. A left femoral vein access was obtained under standard fashion and a cavogram was performed which showed that the bullet to be within the right atrium (Fig. 3). Gentle probing of the bullet region resulted in movement of the bullet by the catheter in the right atrium confirming the intracardiac location of the bullet. The angiography table was then rotated immediately into a 408 upright position (reverse Trendelenburg) to inhibit cephalad migration towards the right ventricle.
* Corresponding author at: Department of Radiology, 450 Clarkson Avenue, Brooklyn, New York 11230, United States. Tel.: +1 718 270 1603. E-mail address: [email protected] (M. Ghanaat). http://dx.doi.org/10.1016/j.injury.2014.07.018 0020–1383/Published by Elsevier Ltd.
Bullet extraction was then performed. A 5 French sheath was exchanged over sequential dilatation for a 14 French long sheath. Through this sheath, a 7 French catheter with a compliant 27 mm occlusion balloon was advanced gently over a guidewire into the right atrium, cephalad to the bullet. The balloon was inflated. The catheter was then pulled down until it moved the bullet. The bullet was then dragged caudad to the balloon through the cavoatrial junction into the inferior vena cava. Continued extraction was performed until the bullet fell into the right renal vein. A second venous catheter was placed via existing right femoral sheath. Through that catheter a six wire basket was advanced into the right renal vein and used to trap the bullet. As the bullet was pulled out of the renal vein, it became dislodged from the basket in the IVC. However the occlusion balloon had been pulled downward as well so the bullet did not go back into the renal vein. Extraction proceeded until the bullet reached the pelvic brim, where it fell by gravity into the right internal iliac vein. Extraction from this vein was not deemed feasible give patient’s condition. Attempts to push the bullet further into that vein were unsuccessful and the orifice of this vein could not be engaged. A 14 mm 4 cm nitinol bare metal stent was placed at the junction of the common and external iliac veins, covering the orifice of the internal iliac vein. This trapped the bullet to prevent remigration (Fig. 4). Thrombus was aspirated from the sheaths. Left femoral sheath was then removed with hemostasis achieved by manual compression. Subsequent hospital course was complicated by pulmonary embolism. The patient was discharged 23 days after admission.
M. Ghanaat et al. / Injury, Int. J. Care Injured 46 (2015) 166–168
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Fig. 1. Portable intraoperative radiograph demonstrates bullet overlying the cardiac silhouette. Fig. 4. Metal stent at the junction of the common and external iliac veins, covering the orifice of the internal iliac vein to prevent remigration. Note occlusive balloon within distal inferior vena cava.
Fig. 2. Chest CT demonstrates bullet in the cavoatrial region.
Discussion Until the mid-20th century, most patients with intracardiac or intravascular bullets died [3]. With advances in medicine and cardiothoracic surgery, retrieval of intracardiac bullets became an
Fig. 3. Digital subtraction venography demonstrates bullet in the right atrium. ‘‘Blurry bullet’’ sign is noted.
option with or without bypass and surgery was usually recommended [3–5]. Since their invention in 1964 by Dotter, percutaneous interventional procedures have become an important and reliable method of bullet retrieval [1,6,7]. Galante and London [4] proposed that in stable patients, left sided intracardiac bullets may be managed surgically, whereas those in the right heart may be managed percutaneously. Intravascular and intracardiac bullets are a diagnostic and therapeutic challenge. The portable chest X-ray may only reveal a bullet in the area of the cardiac silhouette without clear spacial resolution. The ‘‘blurry bullet’’ sign may be present on the radiograph secondary to cardiac motion. This was observed during venography (Fig. 3) and fluoroscopy (Video 1). CT scans, although helpful, are often accompanied by beam hardening artefact that limits detailed localization (Fig. 2). Some have suggested that the use of ultrasound, transthoracic echocardiography, or transesophageal echocardiography may aid in diagnosis and localization [8–10]. However, an arteriogram or a venogram is often necessary to discern the exact position of the bullet [11]. Management should be performed emergently after patient stabilization due to various complications. Intravenous bullets in the iliac vein, renal vein, and hepatic vein have been reported to migrate to or from the IVC [2,8,12]. Such bullets can easily migrate to the right atrium, right ventricle, and the pulmonary vasculature [2]. They may also cause damage to the chordae tendineae or cause arrhythmia. Intaarterial bullets have been reported to cause adverse effects such as limb, cerebral, and ocular ischaemia [4,8,13]. We put the patient in reverse Trendelenburg position to decrease the likelihood of cephalad migration. Although retrieval of a bullet solely with the use of a snare instrument has been performed in the past with ‘‘relative ease’’ [6], a more comprehensive approach involves the use of an occlusion balloon to prevent central migration [1,2,7,14]. Depending on its shape, a bullet may easily escape a snare or a basket instrument. However, an occlusion balloon may have two minor disadvantages. It creates stasis which predisposes to clotting and also creates blockage of flow creating a high pressure system distally. The interventionalist should work swiftly and hold the balloon at all times to prevent its movement from the high flow system. In this
168
M. Ghanaat et al. / Injury, Int. J. Care Injured 46 (2015) 166–168
case, it is likely that the patient’s pulmonary embolism may have been secondary IVC thrombus formed during the procudure. Different methods have been used to stabilize a migratory bullet in the femoral vein such as a balloon catheter sutured to the skin and a retrieval basket [1,2]. A surgical venotomy is often used to retrieve the bullet from the femoral vein which is relatively superficial. Some interventionalists have also retrieved a bullet via the femoral vein using a small groin incision [7] or using a 24-F split renal Amplatz dilator [14]. In this case, the bullet fell by gravity into a nonessential blood vessel and a stent was placed to cage it and avoid remigration as the patient was unstable. In general, bullets in tissue need not be removed unless they impinge on vital structures or can easily be accessed [15]. Inconsequential chronically retained intracardiac bullet has been reported at autopsy [16]. Lead bullets can lead to lead toxicity due to resorption when left in contact with synovial or intracerebral fluid [17], and to arthropathy when left in joints [15]. Although intravascular bullets are not known to cause lead toxicity, they may serve as thrombogenic foci, which also favours removal in possible.
Conclusion Intravenous and right sided intracardiac bullets may safely be managed via interventional methods using an occlusion balloon, snare, and/or a basket. Patients with suspected intravenous bullets should preferably be placed in reverse Trendelenburg position both during the procedure and also during transfer to decrease the likelihood of central migration. Although venotomy may be used to remove a bullet trapped in the common femoral vein, a stent in the common/external iliac veins can effectively prevent the central migration of a bullet in the internal iliac vein.
Conflict of interest The authors report no conflicts of interest related to this case report.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.injury.2014.07.018.
References [1] Sclafani SJ, Mitchell WG. Retrograde venous bullet embolism. J Trauma 1981;21(August (8)):656–7. [2] Sclafani SJ, Shatzkes D, Scalea T. The removal of intravascular bullets by interventional radiology: the prevention of central migration by balloon occlusion – case report. J Trauma 1991;31(October (10)):1423–5. [3] Flick Jr JB. Right ventriculotomy for removal of intracardiac bullet. Ann Surg 1960;151(February (2)):231–4. [4] Galante J, London JA. Left ventricular bullet embolus: a case report and review of the literature. J Emerg Med 2010;39(July (1)). [5] Graham JM, Mattox KL. Right ventricular bullet embolectomy without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1981;82(August (2)):310–3. [6] Nosher JL, Siegel R. Percutaneous retrieval of nonvascular foreign bodies. Radiology 1993;187(June (3)):649–51. [7] Ronsivalle J, Statler J, Venbrux AC, Arepally A. Intravascular bullet migration: a report of two cases. Mil Med 2005;170(December (12)):1044–7. [8] Bonk RT, Harrison SD, Meissner MH. Intravascular bullet localization by sonography. AJR Am J Roentgenol 1996;167(July (1)):152. [9] LiMandri G, Gorenstein LA, Starr JP, Homma S, Auteri J, Gopal AS. Use of transesophageal echocardiography in the detection and consequences of an intracardiac bullet. Am J Emerg Med 1994;12(January (1)):105–6. [10] Hashimi MW, Jenkins DR, McGwier BW, Massey CV, Alpert MA. Comparative efficacy of transthoracic and transesophageal echocardiography in detection of an intracardiac bullet fragment. Chest 1994;106(July (1)):299–300. [11] Abad J, Merino MJ, Alted E. Case report: wandering intravascular bullet with aortic pseudoaneurysm. Clin Radiol 1993;47(May (5)):355–6. [12] Mattox KL, Beall Jr AC, Ennix CL, DeBakey ME. Intravascular migratory bullets. Am J Surg 1979;137(February (2)):192–5. [13] Pacio CI, Murphy MA. B.B. Embolus causing monocular blindness in a 9-yearold boy. Am J Ophthalmol 2002;134(November (5)):776–8. [14] Gaylord GM, Johnsrude IS. Split 24-F amplatz dilator for percutaneous extraction of an intravascular bullet: case report and technical note. Radiology 1989;170(March (3 Pt. 1)):888–9. [15] Sclafani SJ, Vuletin JC, Twersky J. Lead arthropathy: arthritis caused by retained intra-articular bullets. Radiology 1985;156(August (2)): 299–302. [16] Springer J, Newman W, McGoey R. Intravascular bullet embolism to the right atrium. J Forensic Sci Jan 2011;56(January (Suppl. 1)):S259–62. [17] Coon T, Miller M, Shirazi F, Sullivan J. Lead toxicity in a 14-year-old female with retained bullet fragments. Pediatrics 2006;117(January (1)):227–30.
