Management of Bullet Emboli to the Heart and Great Vessels

Management of Bullet Emboli to the Heart and Great Vessels Abstract Introduction Firearm-related injuries account for 20% of all injury-related deaths and are responsible for 105,000 injuries annually. The occurrence of bullet emboli to the heart is exceedingly rare. Given the rarity of emboli, controversy exists over management. The primary endpoint of this study is to establish a management algorithm for venous bullet emboli to the heart. Materials and methods A literature search was performed using PubMed and Google Scholar with the following search terms: cardiac bullet embolus, cardiac missile embolus, and bullet embolus. Any discoverable case report(s) or series after 1960 were included in the review. The following data points were collected: age, sex, presentation, imaging, foreign body entry site, foreign body destination site, management, and outcomes. Results Fifty-four articles met our search criteria. A total of 62 patients with thoracic venous bullet emboli were identified with the following distributions: right atrium (9.7%), right ventricle (54.8%), pulmonary arterial tree (32.3%), and intra-thoracic inferior vena cava (3.2%). Only 11.3% of patients had symptoms directly related to the cardiac venous emboli; however, all patients with acute symptoms underwent immediate intervention. Of those patients with bullet emboli to the pulmonary arterial tree, 45% were observed; whereas, only 20% with emboli to the right heart were observed. Those without signs or symptoms usually underwent an intervention (72.7%). Endovascular retrieval was successful in 53% of attempts. Of the endovascular attempts that failed, 28.6% were observed and 71.4% underwent open retrieval. Those who were asymptomatic and observed had no reported adverse sequelae during the follow-up. No mortalities were discovered in this review. Conclusion Bullet emboli can prove to be a clinical challenge. Adjuncts such as X-ray, computed tomography, transthoracic, and/or transesophageal echocardiography help establish the emboli location. While observation in the asymptomatic patient is reasonable in some circumstances, most patients undergo removal. Removal of bullet cardiac emboli is safe with the availability of modern techniques. INTRODUCTION An estimated 105,000 firearm-related injuries occur annually in the USA annually, resulting in approximately 20% of deaths following injury.1 The occurrence of bullet emboli is very rare (0.3%).2 One must have a heightened suspicion for bullet emboli when an exit wound is absent after sustaining a penetrating trauma. Bullet emboli can prove to be a diagnostic challenge. In 1978, Rich et al2 reported an incidence of 0.3% (22/7,500) for bullet emboli from penetrating vascular trauma cases during the Vietnam conflict. In the Afghanistan and Iraq Wars, a 1.1% (4/346) incidence rate was reported.3 The true incidence in the civilian population is largely unknown. However, the rate may be higher given the prevalence of lower velocity weapons and lower kinetic energy.4 Bullet emboli are categorized as arterial (75%), venous (20%), or paradoxical (5%).5 While arterial emboli are typically managed with immediate removal to prevent distal ischemia, venous cardiac emboli are not well studied. Of concern is migration of shrapnel through the thoracic region to the inferior vena cava (IVC), heart, and/or pulmonary arterial tree. Given the rare occurrence and lack of robust experience at any one institution, controversy exists over the management of bullet emboli. Options include retrieval (via either open surgical or endovascular intervention) or observation. Surgical intervention has remained the primary treatment modality since first described in 1917.6 With the advent of cardiac bypass capabilities, many cardiac emboli were removed with an open-heart procedure with cardiopulmonary bypass if needed, regardless of symptoms.7–9 More recently, selective observation and endovascular interventions have been practiced.10–12 The purpose of this paper is to provide an algorithm to manage venous bullet emboli that traverse to the heart and great vessels based on a current review of the literature and current trends in its management. The phrase “venous bullet emboli” refers to emboli to the right heart or pulmonary arteries (i.e., non-systemic circulation). METHODS A systematic review of retrospective data was performed using PubMed and Google Scholar with the following search terms: cardiac bullet embolus, cardiac missile embolus, and bullet embolus. Any discoverable case reports and series published after 1960 were included in the review. The following data points were collected: age, sex, presentation, imaging, foreign body entry site, foreign body destination site, time of diagnosis (acutely during initial hospital stay versus delayed), management, any presenting symptoms annotated, and reported follow-up. Treatment plans were divided into four groups: observation (Obs), underwent an endovascular intervention (Endo), underwent an open intervention (Open), or management by hybrid approach (Combo). Location for discovery of emboli include: right heart (atrium or ventricle), central vein (IVC and SVC), pulmonary arterial tree, left heart, or distal arterial structures. We excluded articles discussing left heart or proximal aorta bullet emboli to focus our efforts on the management of venous bullet emboli. Data analysis was performed using Microsoft Excel. Descriptive and comparative statistics were used to present the data as frequencies with percentage. RESULTS Fifty-four articles met the search criteria (Table I). A total of 62 patients with thoracic venous bullet emboli were identified, with the majority (89%, n = 62) being male, and an average age of 25 yr. Most articles did not report any follow-up. The longest follow-up time period was 6 yr in a patient who underwent observation for a pulmonary arterial bullet embolus.13 Table I. Overview of Reviewed Case Reports/Series #  Study  Timing of Diagnosis  Entry Site  Final Destination  Management  1  Breeding et al23 (USA)  Acute  Left neck (zone II)  Right ventricle  Sternotomy/endovascular retrieval (basket) via right common femoral vein  2  John and Edmondson24 (England)  Acute  Abdomen  Pulmonary artery  Thoracotomy/arteriotomy  3  O’neill et al25 (USA)  Acute  Abdomen  Right atrium  Endovascular retrieval (snare) via right IJ  4  Wales et al26 (England)  Delayed (4 yr)  Left chest  Right ventricle  Sternotomy (CPB)  5  Greaves et al27 (Scandinavia)  Acute  Left brachiocephalic vein  Right ventricle  Observation  6  Duke et al28 (USA)  Acute  Left globe  Left lower pulm lobe  Observation since critically ill  7  Pan et al29 (USA)  Acute  Abdomen  Infrarenal aorto-caval fistula → right ventricle  Sternotomy (CPB)  8  Hassan et al30 (USA)  Acute  Left chest  Left inferior pulmonary artery  Sternotomy (CPB)  9  Cysne et al31 (Brazil)  Acue  Right subclavian area  Right ventricle  Sternotomy (CPB)  10  Zenelaj et al32 (Albania)  Acute  Abdomen  Right ventricle  Left thoracotomy (without CPB)  11  Ettinger et al33 (Taiwan)  Acute  Right subclavian area  Right ventricle  “Ventriculotomy”  12  Padula et al34 (Brazil)  Acute  Right chest  Right ventricle  Sternotomy (CPB)  13  Wu et al35 (USA)  Delayed (14 yr)  Abdomen  Right ventricle  Right thoracotomy (CPB)  14  Demirkilic et al36 (Turkey)  Acute  Left thigh  Left pulmonary artery  Sternotomy (CPB)  15  Best37 (USA)  Acute  Right flank  Right atrium  Endovascular retrieval (snare) via right femoral vein  16  Bertoldo et al38 (Italy)  Acute  Right chest  Intracardiac IVC  Right thoracotomy to control IVC and Fogarty balloon via left femoral vein  17  Agarwal et al39 (India)  Acute  Right neck  Left inferior pulmonary artery  Left thoracotomy with arteriotomy  18  Kalimi et al40 (USA)  Acute  Right buttock  Internal iliac vein to right ventricle  Endovascular attempt → Sternotomy (CPB)  19  Chen et al41 (USA)  Acute  Right flank  Left inferior PA, right ventricle, atrio-caval junction  Endovascular retrieval (snare) via right IJ  20  Colquhoun et al42 (Scotland)  Acute  Right neck  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  Acute  Left groin  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  21  Bors et al43 (France)  Delayed (3 mo)  Left upper chest  Right ventricle  Sternotomy (CPB)  22  Hartzler44 (USA)  Acute  Left neck  Right ventricle  Endovascular retrieval (bioptome) via right IJ  23  Kaushik and Mandal45 (USA)  Acute  Left flank  Right atrium  Endovascular retrieval (basket) via right femoral vein  24  Headrick et al46 (USA)  Acute  Left epigastrium  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  25  Bining et al47 (Canada)  Acute  Right groin  Right ventricle  Sternotomy (CPB)  26  Lundy et al48 (USA)  Acute  Right chest  Right atrium  Observation  27  Lodder et al49 (Mpumalanga)  Acute  Right back  Left pulmonary artery  Observation  28  Van Arsdell et al50 (USA)  Acute  Hard palate  Right ventricle  Sternotomy (CPB)  29  Shannon et al51 (USA)  Acute  Right thigh  Inferior vena cava  Endovascular retrieval (basket) via left femoral vein  30  Nazir et al52 (Pakistan)  Acute  Back  Right ventricle/IVC  Endovascular retrieval (balloon)  31  Obermeyer et al53 (USA)  Acute  Left buttock  Right ventricle  Observation  32  Michelassi et al54 (USA)  Acute  Right abdomen  Right atrium  Sternotomy (CPB)  33  Nagy et al55 (USA)  Acute  Left flank  Right ventricle  Endovascular retrieval attempt then observation  34  Gandhi et al56 (USA)  Acute  Left shoulder  Right ventricle  Observation  Acute  Left lower extremity  Right ventricle  Observation  Acute  Right upper chest  Right ventricle  Observation  35  Patel et al57 (USA)  Acute  Right lower abdomen  Right atrium  Sternotomy WITHOUT CPB  Acute  Right flank  Left lung  Observation  Acute  Right mid-abdomen  Left lung  Endovascular retrieval (basket)  36  Stephenson et al58 (USA)  Acute  Lower abdomen  Left hilar area  Observation  Acute  Right upper arm  Left hilar area  Left thoracotomy  37  Bartlett et al59 (USA)  Acute  Right thigh/right suprapubic area  Right ventricle  Sternotomy (CPB)  38  Grewal et al60 (USA)  Acute  Left chest  Right ventricle  Sternotomy WITHOUT CPB  39  Fernandez-Ranvier et al61 (USA)  Delayed (2 wk)  Left thigh  Right pulmonary artery (middle lobe)  Endovascular retrieval attempt then observation  40  Ng et al62 (Hong Kong)  Acute  Anterior lower thorax  Pulmonary artery  Observation  41  Graham and Mattox63 (USA)  Acute  Right abdomen  Right ventricle  Thoracotomy/ventriculotomy WITHOUT CPB  42  Amsel et al64 (Belgium)  Acute  Right subclavian area  Right ventricle  Sternotomy (CPB)  43  Kortbeek et al65 (USA)  Acute  Abdomen  Pulmonary artery  Observation  44  Hussein et al66 (U.K.)  Delayed (10 yr)  Thigh  Right ventricle  Observation  45  Norton et al67 (USA)  Acute  Left buttock  Right ventricle  Thoracotomy/ventriculotomy with CPB  Acute  Right abdomen  Right ventricle  Sternotomy (CPB)  Acute  Periumbilical area  Right ventricle  Thoracotomy/atriotomy with CPB  46  Petsas et al68 (USA)  Acute  Right upper abdomen  Right pulmonary artery (lower lobe)  Thoracotomy/pulmonary arteriotomy  47  Soong et al69 (USA)  Acute  Chest (Left brachiocephalic vein)  Right ventricle  Sternotomy (CPB)  48  Quinn70 (USA)  Acute  Abdomen  Right ventricle  Thoracotomy  49  Gupta et al71 (USA)  Acute  Right iliac fossa  Right pulmonary artery (lower lobe)  None  50  Ezberci and Kargi72 (Turkey)  Acute  RUQ abdomen  Left lung (hilum)  Left thoracotomy pulmonary arteriotomy  51  Singer et al73 (USA)  Acute  Left chest  Left pulmonary artery → right pulmonary artery  Left thoracotomy → Endovascular retrieval attempt → Right thoracotomy  52  Jackson et al74 (USA)  Acute  Left chest  Left lower pulmonary lobe  Sternotomy (CPB) (bullet not retrieved)  53  Nally et al75 (USA)  Acute  Left arm  Right lower pulmonary lobe  Removed (no specific description how)  54  Gross et al76 (USA)  Acute  Right chest  Left lower lung lobe → Right pulmonary artery  Endovascular retrieval attempt → Endovascular retrieval attempt 1 mo later → CT surgery/IR combo procedure 1 wk later → Right thoracotomy with right lower lobectomy 8 wk after admission  #  Study  Timing of Diagnosis  Entry Site  Final Destination  Management  1  Breeding et al23 (USA)  Acute  Left neck (zone II)  Right ventricle  Sternotomy/endovascular retrieval (basket) via right common femoral vein  2  John and Edmondson24 (England)  Acute  Abdomen  Pulmonary artery  Thoracotomy/arteriotomy  3  O’neill et al25 (USA)  Acute  Abdomen  Right atrium  Endovascular retrieval (snare) via right IJ  4  Wales et al26 (England)  Delayed (4 yr)  Left chest  Right ventricle  Sternotomy (CPB)  5  Greaves et al27 (Scandinavia)  Acute  Left brachiocephalic vein  Right ventricle  Observation  6  Duke et al28 (USA)  Acute  Left globe  Left lower pulm lobe  Observation since critically ill  7  Pan et al29 (USA)  Acute  Abdomen  Infrarenal aorto-caval fistula → right ventricle  Sternotomy (CPB)  8  Hassan et al30 (USA)  Acute  Left chest  Left inferior pulmonary artery  Sternotomy (CPB)  9  Cysne et al31 (Brazil)  Acue  Right subclavian area  Right ventricle  Sternotomy (CPB)  10  Zenelaj et al32 (Albania)  Acute  Abdomen  Right ventricle  Left thoracotomy (without CPB)  11  Ettinger et al33 (Taiwan)  Acute  Right subclavian area  Right ventricle  “Ventriculotomy”  12  Padula et al34 (Brazil)  Acute  Right chest  Right ventricle  Sternotomy (CPB)  13  Wu et al35 (USA)  Delayed (14 yr)  Abdomen  Right ventricle  Right thoracotomy (CPB)  14  Demirkilic et al36 (Turkey)  Acute  Left thigh  Left pulmonary artery  Sternotomy (CPB)  15  Best37 (USA)  Acute  Right flank  Right atrium  Endovascular retrieval (snare) via right femoral vein  16  Bertoldo et al38 (Italy)  Acute  Right chest  Intracardiac IVC  Right thoracotomy to control IVC and Fogarty balloon via left femoral vein  17  Agarwal et al39 (India)  Acute  Right neck  Left inferior pulmonary artery  Left thoracotomy with arteriotomy  18  Kalimi et al40 (USA)  Acute  Right buttock  Internal iliac vein to right ventricle  Endovascular attempt → Sternotomy (CPB)  19  Chen et al41 (USA)  Acute  Right flank  Left inferior PA, right ventricle, atrio-caval junction  Endovascular retrieval (snare) via right IJ  20  Colquhoun et al42 (Scotland)  Acute  Right neck  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  Acute  Left groin  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  21  Bors et al43 (France)  Delayed (3 mo)  Left upper chest  Right ventricle  Sternotomy (CPB)  22  Hartzler44 (USA)  Acute  Left neck  Right ventricle  Endovascular retrieval (bioptome) via right IJ  23  Kaushik and Mandal45 (USA)  Acute  Left flank  Right atrium  Endovascular retrieval (basket) via right femoral vein  24  Headrick et al46 (USA)  Acute  Left epigastrium  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  25  Bining et al47 (Canada)  Acute  Right groin  Right ventricle  Sternotomy (CPB)  26  Lundy et al48 (USA)  Acute  Right chest  Right atrium  Observation  27  Lodder et al49 (Mpumalanga)  Acute  Right back  Left pulmonary artery  Observation  28  Van Arsdell et al50 (USA)  Acute  Hard palate  Right ventricle  Sternotomy (CPB)  29  Shannon et al51 (USA)  Acute  Right thigh  Inferior vena cava  Endovascular retrieval (basket) via left femoral vein  30  Nazir et al52 (Pakistan)  Acute  Back  Right ventricle/IVC  Endovascular retrieval (balloon)  31  Obermeyer et al53 (USA)  Acute  Left buttock  Right ventricle  Observation  32  Michelassi et al54 (USA)  Acute  Right abdomen  Right atrium  Sternotomy (CPB)  33  Nagy et al55 (USA)  Acute  Left flank  Right ventricle  Endovascular retrieval attempt then observation  34  Gandhi et al56 (USA)  Acute  Left shoulder  Right ventricle  Observation  Acute  Left lower extremity  Right ventricle  Observation  Acute  Right upper chest  Right ventricle  Observation  35  Patel et al57 (USA)  Acute  Right lower abdomen  Right atrium  Sternotomy WITHOUT CPB  Acute  Right flank  Left lung  Observation  Acute  Right mid-abdomen  Left lung  Endovascular retrieval (basket)  36  Stephenson et al58 (USA)  Acute  Lower abdomen  Left hilar area  Observation  Acute  Right upper arm  Left hilar area  Left thoracotomy  37  Bartlett et al59 (USA)  Acute  Right thigh/right suprapubic area  Right ventricle  Sternotomy (CPB)  38  Grewal et al60 (USA)  Acute  Left chest  Right ventricle  Sternotomy WITHOUT CPB  39  Fernandez-Ranvier et al61 (USA)  Delayed (2 wk)  Left thigh  Right pulmonary artery (middle lobe)  Endovascular retrieval attempt then observation  40  Ng et al62 (Hong Kong)  Acute  Anterior lower thorax  Pulmonary artery  Observation  41  Graham and Mattox63 (USA)  Acute  Right abdomen  Right ventricle  Thoracotomy/ventriculotomy WITHOUT CPB  42  Amsel et al64 (Belgium)  Acute  Right subclavian area  Right ventricle  Sternotomy (CPB)  43  Kortbeek et al65 (USA)  Acute  Abdomen  Pulmonary artery  Observation  44  Hussein et al66 (U.K.)  Delayed (10 yr)  Thigh  Right ventricle  Observation  45  Norton et al67 (USA)  Acute  Left buttock  Right ventricle  Thoracotomy/ventriculotomy with CPB  Acute  Right abdomen  Right ventricle  Sternotomy (CPB)  Acute  Periumbilical area  Right ventricle  Thoracotomy/atriotomy with CPB  46  Petsas et al68 (USA)  Acute  Right upper abdomen  Right pulmonary artery (lower lobe)  Thoracotomy/pulmonary arteriotomy  47  Soong et al69 (USA)  Acute  Chest (Left brachiocephalic vein)  Right ventricle  Sternotomy (CPB)  48  Quinn70 (USA)  Acute  Abdomen  Right ventricle  Thoracotomy  49  Gupta et al71 (USA)  Acute  Right iliac fossa  Right pulmonary artery (lower lobe)  None  50  Ezberci and Kargi72 (Turkey)  Acute  RUQ abdomen  Left lung (hilum)  Left thoracotomy pulmonary arteriotomy  51  Singer et al73 (USA)  Acute  Left chest  Left pulmonary artery → right pulmonary artery  Left thoracotomy → Endovascular retrieval attempt → Right thoracotomy  52  Jackson et al74 (USA)  Acute  Left chest  Left lower pulmonary lobe  Sternotomy (CPB) (bullet not retrieved)  53  Nally et al75 (USA)  Acute  Left arm  Right lower pulmonary lobe  Removed (no specific description how)  54  Gross et al76 (USA)  Acute  Right chest  Left lower lung lobe → Right pulmonary artery  Endovascular retrieval attempt → Endovascular retrieval attempt 1 mo later → CT surgery/IR combo procedure 1 wk later → Right thoracotomy with right lower lobectomy 8 wk after admission  Table I. Overview of Reviewed Case Reports/Series #  Study  Timing of Diagnosis  Entry Site  Final Destination  Management  1  Breeding et al23 (USA)  Acute  Left neck (zone II)  Right ventricle  Sternotomy/endovascular retrieval (basket) via right common femoral vein  2  John and Edmondson24 (England)  Acute  Abdomen  Pulmonary artery  Thoracotomy/arteriotomy  3  O’neill et al25 (USA)  Acute  Abdomen  Right atrium  Endovascular retrieval (snare) via right IJ  4  Wales et al26 (England)  Delayed (4 yr)  Left chest  Right ventricle  Sternotomy (CPB)  5  Greaves et al27 (Scandinavia)  Acute  Left brachiocephalic vein  Right ventricle  Observation  6  Duke et al28 (USA)  Acute  Left globe  Left lower pulm lobe  Observation since critically ill  7  Pan et al29 (USA)  Acute  Abdomen  Infrarenal aorto-caval fistula → right ventricle  Sternotomy (CPB)  8  Hassan et al30 (USA)  Acute  Left chest  Left inferior pulmonary artery  Sternotomy (CPB)  9  Cysne et al31 (Brazil)  Acue  Right subclavian area  Right ventricle  Sternotomy (CPB)  10  Zenelaj et al32 (Albania)  Acute  Abdomen  Right ventricle  Left thoracotomy (without CPB)  11  Ettinger et al33 (Taiwan)  Acute  Right subclavian area  Right ventricle  “Ventriculotomy”  12  Padula et al34 (Brazil)  Acute  Right chest  Right ventricle  Sternotomy (CPB)  13  Wu et al35 (USA)  Delayed (14 yr)  Abdomen  Right ventricle  Right thoracotomy (CPB)  14  Demirkilic et al36 (Turkey)  Acute  Left thigh  Left pulmonary artery  Sternotomy (CPB)  15  Best37 (USA)  Acute  Right flank  Right atrium  Endovascular retrieval (snare) via right femoral vein  16  Bertoldo et al38 (Italy)  Acute  Right chest  Intracardiac IVC  Right thoracotomy to control IVC and Fogarty balloon via left femoral vein  17  Agarwal et al39 (India)  Acute  Right neck  Left inferior pulmonary artery  Left thoracotomy with arteriotomy  18  Kalimi et al40 (USA)  Acute  Right buttock  Internal iliac vein to right ventricle  Endovascular attempt → Sternotomy (CPB)  19  Chen et al41 (USA)  Acute  Right flank  Left inferior PA, right ventricle, atrio-caval junction  Endovascular retrieval (snare) via right IJ  20  Colquhoun et al42 (Scotland)  Acute  Right neck  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  Acute  Left groin  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  21  Bors et al43 (France)  Delayed (3 mo)  Left upper chest  Right ventricle  Sternotomy (CPB)  22  Hartzler44 (USA)  Acute  Left neck  Right ventricle  Endovascular retrieval (bioptome) via right IJ  23  Kaushik and Mandal45 (USA)  Acute  Left flank  Right atrium  Endovascular retrieval (basket) via right femoral vein  24  Headrick et al46 (USA)  Acute  Left epigastrium  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  25  Bining et al47 (Canada)  Acute  Right groin  Right ventricle  Sternotomy (CPB)  26  Lundy et al48 (USA)  Acute  Right chest  Right atrium  Observation  27  Lodder et al49 (Mpumalanga)  Acute  Right back  Left pulmonary artery  Observation  28  Van Arsdell et al50 (USA)  Acute  Hard palate  Right ventricle  Sternotomy (CPB)  29  Shannon et al51 (USA)  Acute  Right thigh  Inferior vena cava  Endovascular retrieval (basket) via left femoral vein  30  Nazir et al52 (Pakistan)  Acute  Back  Right ventricle/IVC  Endovascular retrieval (balloon)  31  Obermeyer et al53 (USA)  Acute  Left buttock  Right ventricle  Observation  32  Michelassi et al54 (USA)  Acute  Right abdomen  Right atrium  Sternotomy (CPB)  33  Nagy et al55 (USA)  Acute  Left flank  Right ventricle  Endovascular retrieval attempt then observation  34  Gandhi et al56 (USA)  Acute  Left shoulder  Right ventricle  Observation  Acute  Left lower extremity  Right ventricle  Observation  Acute  Right upper chest  Right ventricle  Observation  35  Patel et al57 (USA)  Acute  Right lower abdomen  Right atrium  Sternotomy WITHOUT CPB  Acute  Right flank  Left lung  Observation  Acute  Right mid-abdomen  Left lung  Endovascular retrieval (basket)  36  Stephenson et al58 (USA)  Acute  Lower abdomen  Left hilar area  Observation  Acute  Right upper arm  Left hilar area  Left thoracotomy  37  Bartlett et al59 (USA)  Acute  Right thigh/right suprapubic area  Right ventricle  Sternotomy (CPB)  38  Grewal et al60 (USA)  Acute  Left chest  Right ventricle  Sternotomy WITHOUT CPB  39  Fernandez-Ranvier et al61 (USA)  Delayed (2 wk)  Left thigh  Right pulmonary artery (middle lobe)  Endovascular retrieval attempt then observation  40  Ng et al62 (Hong Kong)  Acute  Anterior lower thorax  Pulmonary artery  Observation  41  Graham and Mattox63 (USA)  Acute  Right abdomen  Right ventricle  Thoracotomy/ventriculotomy WITHOUT CPB  42  Amsel et al64 (Belgium)  Acute  Right subclavian area  Right ventricle  Sternotomy (CPB)  43  Kortbeek et al65 (USA)  Acute  Abdomen  Pulmonary artery  Observation  44  Hussein et al66 (U.K.)  Delayed (10 yr)  Thigh  Right ventricle  Observation  45  Norton et al67 (USA)  Acute  Left buttock  Right ventricle  Thoracotomy/ventriculotomy with CPB  Acute  Right abdomen  Right ventricle  Sternotomy (CPB)  Acute  Periumbilical area  Right ventricle  Thoracotomy/atriotomy with CPB  46  Petsas et al68 (USA)  Acute  Right upper abdomen  Right pulmonary artery (lower lobe)  Thoracotomy/pulmonary arteriotomy  47  Soong et al69 (USA)  Acute  Chest (Left brachiocephalic vein)  Right ventricle  Sternotomy (CPB)  48  Quinn70 (USA)  Acute  Abdomen  Right ventricle  Thoracotomy  49  Gupta et al71 (USA)  Acute  Right iliac fossa  Right pulmonary artery (lower lobe)  None  50  Ezberci and Kargi72 (Turkey)  Acute  RUQ abdomen  Left lung (hilum)  Left thoracotomy pulmonary arteriotomy  51  Singer et al73 (USA)  Acute  Left chest  Left pulmonary artery → right pulmonary artery  Left thoracotomy → Endovascular retrieval attempt → Right thoracotomy  52  Jackson et al74 (USA)  Acute  Left chest  Left lower pulmonary lobe  Sternotomy (CPB) (bullet not retrieved)  53  Nally et al75 (USA)  Acute  Left arm  Right lower pulmonary lobe  Removed (no specific description how)  54  Gross et al76 (USA)  Acute  Right chest  Left lower lung lobe → Right pulmonary artery  Endovascular retrieval attempt → Endovascular retrieval attempt 1 mo later → CT surgery/IR combo procedure 1 wk later → Right thoracotomy with right lower lobectomy 8 wk after admission  #  Study  Timing of Diagnosis  Entry Site  Final Destination  Management  1  Breeding et al23 (USA)  Acute  Left neck (zone II)  Right ventricle  Sternotomy/endovascular retrieval (basket) via right common femoral vein  2  John and Edmondson24 (England)  Acute  Abdomen  Pulmonary artery  Thoracotomy/arteriotomy  3  O’neill et al25 (USA)  Acute  Abdomen  Right atrium  Endovascular retrieval (snare) via right IJ  4  Wales et al26 (England)  Delayed (4 yr)  Left chest  Right ventricle  Sternotomy (CPB)  5  Greaves et al27 (Scandinavia)  Acute  Left brachiocephalic vein  Right ventricle  Observation  6  Duke et al28 (USA)  Acute  Left globe  Left lower pulm lobe  Observation since critically ill  7  Pan et al29 (USA)  Acute  Abdomen  Infrarenal aorto-caval fistula → right ventricle  Sternotomy (CPB)  8  Hassan et al30 (USA)  Acute  Left chest  Left inferior pulmonary artery  Sternotomy (CPB)  9  Cysne et al31 (Brazil)  Acue  Right subclavian area  Right ventricle  Sternotomy (CPB)  10  Zenelaj et al32 (Albania)  Acute  Abdomen  Right ventricle  Left thoracotomy (without CPB)  11  Ettinger et al33 (Taiwan)  Acute  Right subclavian area  Right ventricle  “Ventriculotomy”  12  Padula et al34 (Brazil)  Acute  Right chest  Right ventricle  Sternotomy (CPB)  13  Wu et al35 (USA)  Delayed (14 yr)  Abdomen  Right ventricle  Right thoracotomy (CPB)  14  Demirkilic et al36 (Turkey)  Acute  Left thigh  Left pulmonary artery  Sternotomy (CPB)  15  Best37 (USA)  Acute  Right flank  Right atrium  Endovascular retrieval (snare) via right femoral vein  16  Bertoldo et al38 (Italy)  Acute  Right chest  Intracardiac IVC  Right thoracotomy to control IVC and Fogarty balloon via left femoral vein  17  Agarwal et al39 (India)  Acute  Right neck  Left inferior pulmonary artery  Left thoracotomy with arteriotomy  18  Kalimi et al40 (USA)  Acute  Right buttock  Internal iliac vein to right ventricle  Endovascular attempt → Sternotomy (CPB)  19  Chen et al41 (USA)  Acute  Right flank  Left inferior PA, right ventricle, atrio-caval junction  Endovascular retrieval (snare) via right IJ  20  Colquhoun et al42 (Scotland)  Acute  Right neck  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  Acute  Left groin  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  21  Bors et al43 (France)  Delayed (3 mo)  Left upper chest  Right ventricle  Sternotomy (CPB)  22  Hartzler44 (USA)  Acute  Left neck  Right ventricle  Endovascular retrieval (bioptome) via right IJ  23  Kaushik and Mandal45 (USA)  Acute  Left flank  Right atrium  Endovascular retrieval (basket) via right femoral vein  24  Headrick et al46 (USA)  Acute  Left epigastrium  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  25  Bining et al47 (Canada)  Acute  Right groin  Right ventricle  Sternotomy (CPB)  26  Lundy et al48 (USA)  Acute  Right chest  Right atrium  Observation  27  Lodder et al49 (Mpumalanga)  Acute  Right back  Left pulmonary artery  Observation  28  Van Arsdell et al50 (USA)  Acute  Hard palate  Right ventricle  Sternotomy (CPB)  29  Shannon et al51 (USA)  Acute  Right thigh  Inferior vena cava  Endovascular retrieval (basket) via left femoral vein  30  Nazir et al52 (Pakistan)  Acute  Back  Right ventricle/IVC  Endovascular retrieval (balloon)  31  Obermeyer et al53 (USA)  Acute  Left buttock  Right ventricle  Observation  32  Michelassi et al54 (USA)  Acute  Right abdomen  Right atrium  Sternotomy (CPB)  33  Nagy et al55 (USA)  Acute  Left flank  Right ventricle  Endovascular retrieval attempt then observation  34  Gandhi et al56 (USA)  Acute  Left shoulder  Right ventricle  Observation  Acute  Left lower extremity  Right ventricle  Observation  Acute  Right upper chest  Right ventricle  Observation  35  Patel et al57 (USA)  Acute  Right lower abdomen  Right atrium  Sternotomy WITHOUT CPB  Acute  Right flank  Left lung  Observation  Acute  Right mid-abdomen  Left lung  Endovascular retrieval (basket)  36  Stephenson et al58 (USA)  Acute  Lower abdomen  Left hilar area  Observation  Acute  Right upper arm  Left hilar area  Left thoracotomy  37  Bartlett et al59 (USA)  Acute  Right thigh/right suprapubic area  Right ventricle  Sternotomy (CPB)  38  Grewal et al60 (USA)  Acute  Left chest  Right ventricle  Sternotomy WITHOUT CPB  39  Fernandez-Ranvier et al61 (USA)  Delayed (2 wk)  Left thigh  Right pulmonary artery (middle lobe)  Endovascular retrieval attempt then observation  40  Ng et al62 (Hong Kong)  Acute  Anterior lower thorax  Pulmonary artery  Observation  41  Graham and Mattox63 (USA)  Acute  Right abdomen  Right ventricle  Thoracotomy/ventriculotomy WITHOUT CPB  42  Amsel et al64 (Belgium)  Acute  Right subclavian area  Right ventricle  Sternotomy (CPB)  43  Kortbeek et al65 (USA)  Acute  Abdomen  Pulmonary artery  Observation  44  Hussein et al66 (U.K.)  Delayed (10 yr)  Thigh  Right ventricle  Observation  45  Norton et al67 (USA)  Acute  Left buttock  Right ventricle  Thoracotomy/ventriculotomy with CPB  Acute  Right abdomen  Right ventricle  Sternotomy (CPB)  Acute  Periumbilical area  Right ventricle  Thoracotomy/atriotomy with CPB  46  Petsas et al68 (USA)  Acute  Right upper abdomen  Right pulmonary artery (lower lobe)  Thoracotomy/pulmonary arteriotomy  47  Soong et al69 (USA)  Acute  Chest (Left brachiocephalic vein)  Right ventricle  Sternotomy (CPB)  48  Quinn70 (USA)  Acute  Abdomen  Right ventricle  Thoracotomy  49  Gupta et al71 (USA)  Acute  Right iliac fossa  Right pulmonary artery (lower lobe)  None  50  Ezberci and Kargi72 (Turkey)  Acute  RUQ abdomen  Left lung (hilum)  Left thoracotomy pulmonary arteriotomy  51  Singer et al73 (USA)  Acute  Left chest  Left pulmonary artery → right pulmonary artery  Left thoracotomy → Endovascular retrieval attempt → Right thoracotomy  52  Jackson et al74 (USA)  Acute  Left chest  Left lower pulmonary lobe  Sternotomy (CPB) (bullet not retrieved)  53  Nally et al75 (USA)  Acute  Left arm  Right lower pulmonary lobe  Removed (no specific description how)  54  Gross et al76 (USA)  Acute  Right chest  Left lower lung lobe → Right pulmonary artery  Endovascular retrieval attempt → Endovascular retrieval attempt 1 mo later → CT surgery/IR combo procedure 1 wk later → Right thoracotomy with right lower lobectomy 8 wk after admission  Figure 1 depicts number of patients by treatment group and location, with frequency of locations as follows: right ventricle (54.8%, n = 34), pulmonary arterial tree (32.3%, n = 20), right atrium (9.7%, n = 6), and intra-thoracic IVC (3.2%, n = 2). Most patients (88.7%, n = 55) were asymptomatic from the bullet emboli to the thoracic cavity. Those without signs or symptoms were either observed (27%, n = 15) or underwent an intervention (73%, n = 40). FIGURE 1. View largeDownload slide Overview of results. FIGURE 1. View largeDownload slide Overview of results. Table I lists the timing of diagnosis, entry site of the bullet, final destination of the bullet, and overall management. All but five of the patients were diagnosed acutely. Four patients had a documented bullet entry site in the neck (i.e., internal jugular veins), 18 in the chest (i.e., subclavian, brachiocephalic veins or superior/inferior vena cava), 22 in the back, flank or abdomen (i.e., inferior vena cava, renal or iliac veins), and 14 in an extremity or pelvis (i.e., axillary, brachial, iliac, or femoral veins). Seven of 62 patients (11.3%) demonstrated symptoms directly related to the cardiac venous emboli. Symptoms ranged from chest pain, dyspnea, or fever. Of these, four patients reported acute symptoms related to the missile embolus and all four patients underwent immediate open intervention successfully. Three patients presented with delayed symptoms (4–14 yr after initial injury) and TWO of these patients underwent successful retrieval via an open approach. The one symptomatic patient that was observed successfully presented 10 yr after his initial injury and reported no adverse sequelae. Of those patients with bullet emboli to the pulmonary arterial tree, 45% (n = 9) were observed; whereas, only 20% (n = 8) of patients with emboli to the right heart were observed. Most (92%, n = 57) patients were diagnosed acutely; whereas, 8% (n = 5) were diagnosed later. Of the five patients with a delayed diagnosis, 2 (40%) were discovered incidentally and 3 (60%) were discovered due to reported symptoms. Endovascular retrieval was successful in 53.3% (n = 8) of attempts. Of the seven initial endovascular attempts that failed, 28.6% (n = 2) were observed and 71.4% (n = 5) underwent open retrieval. Those who were asymptomatic and observed (n = 15) had no adverse sequelae during the reported follow-up. Lastly, in all of the reported cases, no mortalities were recorded and no complication rates were discussed. DISCUSSION Bullet emboli that enter the venous system most commonly migrate to the right heart. From the right heart, they may migrate to the pulmonary arterial tree. In 1987, Shannon et al,14 retrospectively reviewed 126 cases of venous bullet emboli and reported that 48% will lodge in the right heart, 36% will continue into the pulmonary circulation, and 16% will enter the peripheral/central veins. Our analysis supports this finding, demonstrating that the majority (64.7%) of venous emboli go to the right heart. The risk of paradoxic embolization to the arterial system is low. This usually occurs through a patent foramen ovale.14 Most foreign bodies that travel to the right ventricle will catch the chordopapillary apparatus of the tricuspid valve or the ventricular trebeculae.15 Indeed, most of the emboli were located in the right ventricle (58%).7,16–18 In a previous study by Michelassi et al,8 the authors identified several factors that contributed to the emboli’s destination. These factors include blood flow, body position, gravity, respiratory movements, and the missile’s caliber and weight. Historically, 70% of patients with venous bullet emboli are reportedly asymptomatic.5 Our review demonstrates nearly 90% of patients were asymptomatic; however, patients may present later with symptoms, in some cases months or years after the initial injury. The presenting symptoms are often signs of complications that need urgent intervention. Complications include valvular dysfunction, bacterial endocarditis, myocardial irritability, erosion of the bullet through the cardiac tissue, embolization to the pulmonary vasculature with resulting infarction and abscess formation, and “cardiac neurosis.”19–22 “Cardiac neurosis” refers to the anxiety reaction that a patient experiences after realizing that they have a bullet in their heart. The anxiety reaction can be characterized by fatigue, shortness of breath, rapid heartbeat, dizziness and other cardiac symptoms that are not caused by an actual disease of the heart. Shannon et al. conducted a review in 1987 of venous bullet emboli, which included 51 initially asymptomatic patients in whom missile emboli were not removed. When the projectile was not removed in these patients, 25% (13) of them developed complications and 6% (3) of them died.14 With today’s imaging modalities, the identification of the exact location of the bullet is often confirmed. However, further migration can occur. Adjuncts such as X-ray (Fig. 2), computed tomography (CT), transthoracic, and/or transesophageal echocardiography (TTE/TEE) may help establish the specific location. Once the fragment is located there are several options for management. FIGURE 2. View largeDownload slide Chest X-ray demonstrating a bullet embolus in the right heart (red arrow). FIGURE 2. View largeDownload slide Chest X-ray demonstrating a bullet embolus in the right heart (red arrow). Management options of venous bullet emboli include observation, endovascular extraction or open surgical retrieval. Open surgical intervention may include thoracotomy and sternotomy with or without cardiopulmonary bypass. The first report of an endovascular intervention for venous bullet emboli to the heart was in 1980 by Hartzler.77 Technical advancements in endovascular management since then have resulted in less morbidity and mortality.78 Our data do not fully account for the rapid advancement with interventional medicine (cardiology, radiology, or vascular surgery). Therefore, not all time frames reviewed included these more modern endovascular capabilities. A review of all the available literature over the course of 55 yr demonstrates the rate of successful endovascular retrieval (as the primary treatment) for all patients who underwent percutaneous intervention at 53%. Given the increased safety of endovascular intervention, some support the prophylactic retrieval of bullet emboli to avoid future complications.79 Removal of bullet emboli is safe with the availability of modern techniques (1–2% complication rate).14 When endovascular means alone are not sufficient, some authors have discussed a hybrid approach to remove the venous bullet emboli.4 The available data support the safety and efficiency of bullet emboli removal. However, while it may be safe to remove the bullet emboli, the need to remove it remains less clear. Some authors recommend that any bullet less than 5 mm, firmly lodged, and not causing arrhythmia or valvular dysfunction should not be retrieved.2,14,15 Observation can also be applied to patients who have bullets in the pulmonary tree that have no signs or symptoms concerning for pulmonary infarction, pulmonary abscess, or erosion in the bronchus.15 Those patients with cardiac emboli that become symptomatic should have the foreign body removed.14 From this review of the data, we propose the following algorithm. (Fig. 3) Patients with venous bullet emboli that exhibit symptoms should undergo retrieval. Endovascular extraction is an appropriate first-line treatment option when resources are available. If endovascular attempts fail, then open surgical retrieval should be considered. We also recommend that any patient with an atrial septal defect, ventral septal defect, or patent foraman ovale should undergo retrieval given the concern for stroke or distal emboli causing ischemia. A patient with asymptomatic emboli to the pulmonary artery can be observed; however, retrieval is recommended if the patient develops symptoms. FIGURE 3. View largeDownload slide Management algorithm for venous bullet emboli. FIGURE 3. View largeDownload slide Management algorithm for venous bullet emboli. If the bullet embolus is discovered in the right heart (atrium or ventricle) or central vein (IVC), we recommend an initial attempt at percutaneous retrieval unless the following criteria for observation are met: bullet <5 mm in diameter, smooth in appearance, firmly lodged, uncontaminated, and patient is hemodynamically stable without evidence of arrhythmias or valvular dysfunction. Patients with bullet emboli who meet these criteria can be safely observed and undergo serial imaging. In the event that the attempt at percutaneous retrieval from the right heart or central vein fails, we recommend that the patient then undergo open (sternotomy, thoracotomy) hybrid retrieval attempts. The surgical approach is determined by a combination of the location of the bullet and the surgeon’s preference. Most patients would require cardiopulmonary bypass as well. Bullet emboli discovered in the pulmonary arterial tree may be safely observed with serial imaging; however, if the patient develops symptoms (i.e., pulmonary infarction and abscess formation), then we recommend open retrieval of the foreign body. Percutaneous retrieval attempts have been associated with high failure rates and will likely lead to repeated procedures and resources in the management of pulmonary arterial bullet emboli. In all of the reported cases no mortalities were recorded. Most likely those that died from the initial injury, initial surgery, or during subsequent attempts at retrieval were not reported and the publication selection bias may be substantial. The lack of reported clinical follow-up is a major limitation for this review. There are several other limitations to this study. The removal of most cardiac emboli was performed without any symptoms or signs of injury. There are no randomized trials comparing leaving cardiac emboli in situ versus retrieving the foreign body. It is possible that many of the fragments could have been left in situ. Therefore, while a majority of cardiac emboli were retrieved, the evidence supporting retrieval is not backed by strong scientific research. However, the rate of symptoms (versus potential symptoms or potential complications) is most likely under-reported as the cardiac emboli were more often removed close to the time of diagnosis, thus preventing symptoms or complications from occurring. More studies are clearly warranted for this uncommon, but perplexing condition. Performing a review of retrospective data also lends itself to a selection bias since there is a tendency to report positive findings and discuss those patients who did well clinically. Additionally, there is the inherent risk of error in compiling or inputting data. We feel that the approach must be individualized to the patient’s specific clinical course; however, given the safety of modern technology and techniques, most patients should undergo intervention especially when the diagnosis of cardiac bullet embolus is made acutely. CONCLUSION Bullet emboli can prove to be a clinical challenge with removal made safer with the availability of modern techniques. Adjuncts such as X-ray, CT, transthoracic, and/or transesophageal echocardiography may help establish the diagnosis. The approach must be individualized to the patient’s specific clinical course, however most patients should undergo intervention. References 1 Gotsch KE, Annest JL, Mercy JA, Ryan GW: Surveillance for fatal and nonfatal firearm-related injuries – United States, 1993-1998. MMWR  2001; 50( SS02): 1– 32. 2 Rich NM, Collinsc GJ, Andersen CA, McDonald PT, Kozloff L, Ricotta JJ: Missile emboli. 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Google Scholar PubMed  77 Hartzler GO: Percutaneous transvenous removal of a bullet embolus to the right ventricle. J Thorac Cardiovasc Surg  1980; 80( 1): 153– 5. Google Scholar PubMed  78 Schroeder ME, Pryor HI, Chun AK, Rahbar R, Arora S, Vaziri K: Retrograde migration and endovascular retrieval of a venous bullet embolus. J Vasc Surg  2011; 53( 4): 1113– 5. Google Scholar CrossRef Search ADS PubMed  79 Miller KR, Benns MV, Sciarretta JD, et al.  : The evolving management of venous bullet emboli: a case series and literature review. Injury  2011; 42( 5): 441– 6. Google Scholar CrossRef Search ADS PubMed  Author notes The views expressed in this manuscript are those of the authors and do not reflect the official policy of the William Beaumont Army Medical Center, the Uniformed Services University of the Health Sciences, the Department of the Army, the Department of Defense, or the US Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Management of Bullet Emboli to the Heart and Great Vessels

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Association of Military Surgeons of the United States
Copyright
Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.
ISSN
0026-4075
eISSN
1930-613X
D.O.I.
10.1093/milmed/usx191
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Abstract

Abstract Introduction Firearm-related injuries account for 20% of all injury-related deaths and are responsible for 105,000 injuries annually. The occurrence of bullet emboli to the heart is exceedingly rare. Given the rarity of emboli, controversy exists over management. The primary endpoint of this study is to establish a management algorithm for venous bullet emboli to the heart. Materials and methods A literature search was performed using PubMed and Google Scholar with the following search terms: cardiac bullet embolus, cardiac missile embolus, and bullet embolus. Any discoverable case report(s) or series after 1960 were included in the review. The following data points were collected: age, sex, presentation, imaging, foreign body entry site, foreign body destination site, management, and outcomes. Results Fifty-four articles met our search criteria. A total of 62 patients with thoracic venous bullet emboli were identified with the following distributions: right atrium (9.7%), right ventricle (54.8%), pulmonary arterial tree (32.3%), and intra-thoracic inferior vena cava (3.2%). Only 11.3% of patients had symptoms directly related to the cardiac venous emboli; however, all patients with acute symptoms underwent immediate intervention. Of those patients with bullet emboli to the pulmonary arterial tree, 45% were observed; whereas, only 20% with emboli to the right heart were observed. Those without signs or symptoms usually underwent an intervention (72.7%). Endovascular retrieval was successful in 53% of attempts. Of the endovascular attempts that failed, 28.6% were observed and 71.4% underwent open retrieval. Those who were asymptomatic and observed had no reported adverse sequelae during the follow-up. No mortalities were discovered in this review. Conclusion Bullet emboli can prove to be a clinical challenge. Adjuncts such as X-ray, computed tomography, transthoracic, and/or transesophageal echocardiography help establish the emboli location. While observation in the asymptomatic patient is reasonable in some circumstances, most patients undergo removal. Removal of bullet cardiac emboli is safe with the availability of modern techniques. INTRODUCTION An estimated 105,000 firearm-related injuries occur annually in the USA annually, resulting in approximately 20% of deaths following injury.1 The occurrence of bullet emboli is very rare (0.3%).2 One must have a heightened suspicion for bullet emboli when an exit wound is absent after sustaining a penetrating trauma. Bullet emboli can prove to be a diagnostic challenge. In 1978, Rich et al2 reported an incidence of 0.3% (22/7,500) for bullet emboli from penetrating vascular trauma cases during the Vietnam conflict. In the Afghanistan and Iraq Wars, a 1.1% (4/346) incidence rate was reported.3 The true incidence in the civilian population is largely unknown. However, the rate may be higher given the prevalence of lower velocity weapons and lower kinetic energy.4 Bullet emboli are categorized as arterial (75%), venous (20%), or paradoxical (5%).5 While arterial emboli are typically managed with immediate removal to prevent distal ischemia, venous cardiac emboli are not well studied. Of concern is migration of shrapnel through the thoracic region to the inferior vena cava (IVC), heart, and/or pulmonary arterial tree. Given the rare occurrence and lack of robust experience at any one institution, controversy exists over the management of bullet emboli. Options include retrieval (via either open surgical or endovascular intervention) or observation. Surgical intervention has remained the primary treatment modality since first described in 1917.6 With the advent of cardiac bypass capabilities, many cardiac emboli were removed with an open-heart procedure with cardiopulmonary bypass if needed, regardless of symptoms.7–9 More recently, selective observation and endovascular interventions have been practiced.10–12 The purpose of this paper is to provide an algorithm to manage venous bullet emboli that traverse to the heart and great vessels based on a current review of the literature and current trends in its management. The phrase “venous bullet emboli” refers to emboli to the right heart or pulmonary arteries (i.e., non-systemic circulation). METHODS A systematic review of retrospective data was performed using PubMed and Google Scholar with the following search terms: cardiac bullet embolus, cardiac missile embolus, and bullet embolus. Any discoverable case reports and series published after 1960 were included in the review. The following data points were collected: age, sex, presentation, imaging, foreign body entry site, foreign body destination site, time of diagnosis (acutely during initial hospital stay versus delayed), management, any presenting symptoms annotated, and reported follow-up. Treatment plans were divided into four groups: observation (Obs), underwent an endovascular intervention (Endo), underwent an open intervention (Open), or management by hybrid approach (Combo). Location for discovery of emboli include: right heart (atrium or ventricle), central vein (IVC and SVC), pulmonary arterial tree, left heart, or distal arterial structures. We excluded articles discussing left heart or proximal aorta bullet emboli to focus our efforts on the management of venous bullet emboli. Data analysis was performed using Microsoft Excel. Descriptive and comparative statistics were used to present the data as frequencies with percentage. RESULTS Fifty-four articles met the search criteria (Table I). A total of 62 patients with thoracic venous bullet emboli were identified, with the majority (89%, n = 62) being male, and an average age of 25 yr. Most articles did not report any follow-up. The longest follow-up time period was 6 yr in a patient who underwent observation for a pulmonary arterial bullet embolus.13 Table I. Overview of Reviewed Case Reports/Series #  Study  Timing of Diagnosis  Entry Site  Final Destination  Management  1  Breeding et al23 (USA)  Acute  Left neck (zone II)  Right ventricle  Sternotomy/endovascular retrieval (basket) via right common femoral vein  2  John and Edmondson24 (England)  Acute  Abdomen  Pulmonary artery  Thoracotomy/arteriotomy  3  O’neill et al25 (USA)  Acute  Abdomen  Right atrium  Endovascular retrieval (snare) via right IJ  4  Wales et al26 (England)  Delayed (4 yr)  Left chest  Right ventricle  Sternotomy (CPB)  5  Greaves et al27 (Scandinavia)  Acute  Left brachiocephalic vein  Right ventricle  Observation  6  Duke et al28 (USA)  Acute  Left globe  Left lower pulm lobe  Observation since critically ill  7  Pan et al29 (USA)  Acute  Abdomen  Infrarenal aorto-caval fistula → right ventricle  Sternotomy (CPB)  8  Hassan et al30 (USA)  Acute  Left chest  Left inferior pulmonary artery  Sternotomy (CPB)  9  Cysne et al31 (Brazil)  Acue  Right subclavian area  Right ventricle  Sternotomy (CPB)  10  Zenelaj et al32 (Albania)  Acute  Abdomen  Right ventricle  Left thoracotomy (without CPB)  11  Ettinger et al33 (Taiwan)  Acute  Right subclavian area  Right ventricle  “Ventriculotomy”  12  Padula et al34 (Brazil)  Acute  Right chest  Right ventricle  Sternotomy (CPB)  13  Wu et al35 (USA)  Delayed (14 yr)  Abdomen  Right ventricle  Right thoracotomy (CPB)  14  Demirkilic et al36 (Turkey)  Acute  Left thigh  Left pulmonary artery  Sternotomy (CPB)  15  Best37 (USA)  Acute  Right flank  Right atrium  Endovascular retrieval (snare) via right femoral vein  16  Bertoldo et al38 (Italy)  Acute  Right chest  Intracardiac IVC  Right thoracotomy to control IVC and Fogarty balloon via left femoral vein  17  Agarwal et al39 (India)  Acute  Right neck  Left inferior pulmonary artery  Left thoracotomy with arteriotomy  18  Kalimi et al40 (USA)  Acute  Right buttock  Internal iliac vein to right ventricle  Endovascular attempt → Sternotomy (CPB)  19  Chen et al41 (USA)  Acute  Right flank  Left inferior PA, right ventricle, atrio-caval junction  Endovascular retrieval (snare) via right IJ  20  Colquhoun et al42 (Scotland)  Acute  Right neck  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  Acute  Left groin  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  21  Bors et al43 (France)  Delayed (3 mo)  Left upper chest  Right ventricle  Sternotomy (CPB)  22  Hartzler44 (USA)  Acute  Left neck  Right ventricle  Endovascular retrieval (bioptome) via right IJ  23  Kaushik and Mandal45 (USA)  Acute  Left flank  Right atrium  Endovascular retrieval (basket) via right femoral vein  24  Headrick et al46 (USA)  Acute  Left epigastrium  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  25  Bining et al47 (Canada)  Acute  Right groin  Right ventricle  Sternotomy (CPB)  26  Lundy et al48 (USA)  Acute  Right chest  Right atrium  Observation  27  Lodder et al49 (Mpumalanga)  Acute  Right back  Left pulmonary artery  Observation  28  Van Arsdell et al50 (USA)  Acute  Hard palate  Right ventricle  Sternotomy (CPB)  29  Shannon et al51 (USA)  Acute  Right thigh  Inferior vena cava  Endovascular retrieval (basket) via left femoral vein  30  Nazir et al52 (Pakistan)  Acute  Back  Right ventricle/IVC  Endovascular retrieval (balloon)  31  Obermeyer et al53 (USA)  Acute  Left buttock  Right ventricle  Observation  32  Michelassi et al54 (USA)  Acute  Right abdomen  Right atrium  Sternotomy (CPB)  33  Nagy et al55 (USA)  Acute  Left flank  Right ventricle  Endovascular retrieval attempt then observation  34  Gandhi et al56 (USA)  Acute  Left shoulder  Right ventricle  Observation  Acute  Left lower extremity  Right ventricle  Observation  Acute  Right upper chest  Right ventricle  Observation  35  Patel et al57 (USA)  Acute  Right lower abdomen  Right atrium  Sternotomy WITHOUT CPB  Acute  Right flank  Left lung  Observation  Acute  Right mid-abdomen  Left lung  Endovascular retrieval (basket)  36  Stephenson et al58 (USA)  Acute  Lower abdomen  Left hilar area  Observation  Acute  Right upper arm  Left hilar area  Left thoracotomy  37  Bartlett et al59 (USA)  Acute  Right thigh/right suprapubic area  Right ventricle  Sternotomy (CPB)  38  Grewal et al60 (USA)  Acute  Left chest  Right ventricle  Sternotomy WITHOUT CPB  39  Fernandez-Ranvier et al61 (USA)  Delayed (2 wk)  Left thigh  Right pulmonary artery (middle lobe)  Endovascular retrieval attempt then observation  40  Ng et al62 (Hong Kong)  Acute  Anterior lower thorax  Pulmonary artery  Observation  41  Graham and Mattox63 (USA)  Acute  Right abdomen  Right ventricle  Thoracotomy/ventriculotomy WITHOUT CPB  42  Amsel et al64 (Belgium)  Acute  Right subclavian area  Right ventricle  Sternotomy (CPB)  43  Kortbeek et al65 (USA)  Acute  Abdomen  Pulmonary artery  Observation  44  Hussein et al66 (U.K.)  Delayed (10 yr)  Thigh  Right ventricle  Observation  45  Norton et al67 (USA)  Acute  Left buttock  Right ventricle  Thoracotomy/ventriculotomy with CPB  Acute  Right abdomen  Right ventricle  Sternotomy (CPB)  Acute  Periumbilical area  Right ventricle  Thoracotomy/atriotomy with CPB  46  Petsas et al68 (USA)  Acute  Right upper abdomen  Right pulmonary artery (lower lobe)  Thoracotomy/pulmonary arteriotomy  47  Soong et al69 (USA)  Acute  Chest (Left brachiocephalic vein)  Right ventricle  Sternotomy (CPB)  48  Quinn70 (USA)  Acute  Abdomen  Right ventricle  Thoracotomy  49  Gupta et al71 (USA)  Acute  Right iliac fossa  Right pulmonary artery (lower lobe)  None  50  Ezberci and Kargi72 (Turkey)  Acute  RUQ abdomen  Left lung (hilum)  Left thoracotomy pulmonary arteriotomy  51  Singer et al73 (USA)  Acute  Left chest  Left pulmonary artery → right pulmonary artery  Left thoracotomy → Endovascular retrieval attempt → Right thoracotomy  52  Jackson et al74 (USA)  Acute  Left chest  Left lower pulmonary lobe  Sternotomy (CPB) (bullet not retrieved)  53  Nally et al75 (USA)  Acute  Left arm  Right lower pulmonary lobe  Removed (no specific description how)  54  Gross et al76 (USA)  Acute  Right chest  Left lower lung lobe → Right pulmonary artery  Endovascular retrieval attempt → Endovascular retrieval attempt 1 mo later → CT surgery/IR combo procedure 1 wk later → Right thoracotomy with right lower lobectomy 8 wk after admission  #  Study  Timing of Diagnosis  Entry Site  Final Destination  Management  1  Breeding et al23 (USA)  Acute  Left neck (zone II)  Right ventricle  Sternotomy/endovascular retrieval (basket) via right common femoral vein  2  John and Edmondson24 (England)  Acute  Abdomen  Pulmonary artery  Thoracotomy/arteriotomy  3  O’neill et al25 (USA)  Acute  Abdomen  Right atrium  Endovascular retrieval (snare) via right IJ  4  Wales et al26 (England)  Delayed (4 yr)  Left chest  Right ventricle  Sternotomy (CPB)  5  Greaves et al27 (Scandinavia)  Acute  Left brachiocephalic vein  Right ventricle  Observation  6  Duke et al28 (USA)  Acute  Left globe  Left lower pulm lobe  Observation since critically ill  7  Pan et al29 (USA)  Acute  Abdomen  Infrarenal aorto-caval fistula → right ventricle  Sternotomy (CPB)  8  Hassan et al30 (USA)  Acute  Left chest  Left inferior pulmonary artery  Sternotomy (CPB)  9  Cysne et al31 (Brazil)  Acue  Right subclavian area  Right ventricle  Sternotomy (CPB)  10  Zenelaj et al32 (Albania)  Acute  Abdomen  Right ventricle  Left thoracotomy (without CPB)  11  Ettinger et al33 (Taiwan)  Acute  Right subclavian area  Right ventricle  “Ventriculotomy”  12  Padula et al34 (Brazil)  Acute  Right chest  Right ventricle  Sternotomy (CPB)  13  Wu et al35 (USA)  Delayed (14 yr)  Abdomen  Right ventricle  Right thoracotomy (CPB)  14  Demirkilic et al36 (Turkey)  Acute  Left thigh  Left pulmonary artery  Sternotomy (CPB)  15  Best37 (USA)  Acute  Right flank  Right atrium  Endovascular retrieval (snare) via right femoral vein  16  Bertoldo et al38 (Italy)  Acute  Right chest  Intracardiac IVC  Right thoracotomy to control IVC and Fogarty balloon via left femoral vein  17  Agarwal et al39 (India)  Acute  Right neck  Left inferior pulmonary artery  Left thoracotomy with arteriotomy  18  Kalimi et al40 (USA)  Acute  Right buttock  Internal iliac vein to right ventricle  Endovascular attempt → Sternotomy (CPB)  19  Chen et al41 (USA)  Acute  Right flank  Left inferior PA, right ventricle, atrio-caval junction  Endovascular retrieval (snare) via right IJ  20  Colquhoun et al42 (Scotland)  Acute  Right neck  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  Acute  Left groin  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  21  Bors et al43 (France)  Delayed (3 mo)  Left upper chest  Right ventricle  Sternotomy (CPB)  22  Hartzler44 (USA)  Acute  Left neck  Right ventricle  Endovascular retrieval (bioptome) via right IJ  23  Kaushik and Mandal45 (USA)  Acute  Left flank  Right atrium  Endovascular retrieval (basket) via right femoral vein  24  Headrick et al46 (USA)  Acute  Left epigastrium  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  25  Bining et al47 (Canada)  Acute  Right groin  Right ventricle  Sternotomy (CPB)  26  Lundy et al48 (USA)  Acute  Right chest  Right atrium  Observation  27  Lodder et al49 (Mpumalanga)  Acute  Right back  Left pulmonary artery  Observation  28  Van Arsdell et al50 (USA)  Acute  Hard palate  Right ventricle  Sternotomy (CPB)  29  Shannon et al51 (USA)  Acute  Right thigh  Inferior vena cava  Endovascular retrieval (basket) via left femoral vein  30  Nazir et al52 (Pakistan)  Acute  Back  Right ventricle/IVC  Endovascular retrieval (balloon)  31  Obermeyer et al53 (USA)  Acute  Left buttock  Right ventricle  Observation  32  Michelassi et al54 (USA)  Acute  Right abdomen  Right atrium  Sternotomy (CPB)  33  Nagy et al55 (USA)  Acute  Left flank  Right ventricle  Endovascular retrieval attempt then observation  34  Gandhi et al56 (USA)  Acute  Left shoulder  Right ventricle  Observation  Acute  Left lower extremity  Right ventricle  Observation  Acute  Right upper chest  Right ventricle  Observation  35  Patel et al57 (USA)  Acute  Right lower abdomen  Right atrium  Sternotomy WITHOUT CPB  Acute  Right flank  Left lung  Observation  Acute  Right mid-abdomen  Left lung  Endovascular retrieval (basket)  36  Stephenson et al58 (USA)  Acute  Lower abdomen  Left hilar area  Observation  Acute  Right upper arm  Left hilar area  Left thoracotomy  37  Bartlett et al59 (USA)  Acute  Right thigh/right suprapubic area  Right ventricle  Sternotomy (CPB)  38  Grewal et al60 (USA)  Acute  Left chest  Right ventricle  Sternotomy WITHOUT CPB  39  Fernandez-Ranvier et al61 (USA)  Delayed (2 wk)  Left thigh  Right pulmonary artery (middle lobe)  Endovascular retrieval attempt then observation  40  Ng et al62 (Hong Kong)  Acute  Anterior lower thorax  Pulmonary artery  Observation  41  Graham and Mattox63 (USA)  Acute  Right abdomen  Right ventricle  Thoracotomy/ventriculotomy WITHOUT CPB  42  Amsel et al64 (Belgium)  Acute  Right subclavian area  Right ventricle  Sternotomy (CPB)  43  Kortbeek et al65 (USA)  Acute  Abdomen  Pulmonary artery  Observation  44  Hussein et al66 (U.K.)  Delayed (10 yr)  Thigh  Right ventricle  Observation  45  Norton et al67 (USA)  Acute  Left buttock  Right ventricle  Thoracotomy/ventriculotomy with CPB  Acute  Right abdomen  Right ventricle  Sternotomy (CPB)  Acute  Periumbilical area  Right ventricle  Thoracotomy/atriotomy with CPB  46  Petsas et al68 (USA)  Acute  Right upper abdomen  Right pulmonary artery (lower lobe)  Thoracotomy/pulmonary arteriotomy  47  Soong et al69 (USA)  Acute  Chest (Left brachiocephalic vein)  Right ventricle  Sternotomy (CPB)  48  Quinn70 (USA)  Acute  Abdomen  Right ventricle  Thoracotomy  49  Gupta et al71 (USA)  Acute  Right iliac fossa  Right pulmonary artery (lower lobe)  None  50  Ezberci and Kargi72 (Turkey)  Acute  RUQ abdomen  Left lung (hilum)  Left thoracotomy pulmonary arteriotomy  51  Singer et al73 (USA)  Acute  Left chest  Left pulmonary artery → right pulmonary artery  Left thoracotomy → Endovascular retrieval attempt → Right thoracotomy  52  Jackson et al74 (USA)  Acute  Left chest  Left lower pulmonary lobe  Sternotomy (CPB) (bullet not retrieved)  53  Nally et al75 (USA)  Acute  Left arm  Right lower pulmonary lobe  Removed (no specific description how)  54  Gross et al76 (USA)  Acute  Right chest  Left lower lung lobe → Right pulmonary artery  Endovascular retrieval attempt → Endovascular retrieval attempt 1 mo later → CT surgery/IR combo procedure 1 wk later → Right thoracotomy with right lower lobectomy 8 wk after admission  Table I. Overview of Reviewed Case Reports/Series #  Study  Timing of Diagnosis  Entry Site  Final Destination  Management  1  Breeding et al23 (USA)  Acute  Left neck (zone II)  Right ventricle  Sternotomy/endovascular retrieval (basket) via right common femoral vein  2  John and Edmondson24 (England)  Acute  Abdomen  Pulmonary artery  Thoracotomy/arteriotomy  3  O’neill et al25 (USA)  Acute  Abdomen  Right atrium  Endovascular retrieval (snare) via right IJ  4  Wales et al26 (England)  Delayed (4 yr)  Left chest  Right ventricle  Sternotomy (CPB)  5  Greaves et al27 (Scandinavia)  Acute  Left brachiocephalic vein  Right ventricle  Observation  6  Duke et al28 (USA)  Acute  Left globe  Left lower pulm lobe  Observation since critically ill  7  Pan et al29 (USA)  Acute  Abdomen  Infrarenal aorto-caval fistula → right ventricle  Sternotomy (CPB)  8  Hassan et al30 (USA)  Acute  Left chest  Left inferior pulmonary artery  Sternotomy (CPB)  9  Cysne et al31 (Brazil)  Acue  Right subclavian area  Right ventricle  Sternotomy (CPB)  10  Zenelaj et al32 (Albania)  Acute  Abdomen  Right ventricle  Left thoracotomy (without CPB)  11  Ettinger et al33 (Taiwan)  Acute  Right subclavian area  Right ventricle  “Ventriculotomy”  12  Padula et al34 (Brazil)  Acute  Right chest  Right ventricle  Sternotomy (CPB)  13  Wu et al35 (USA)  Delayed (14 yr)  Abdomen  Right ventricle  Right thoracotomy (CPB)  14  Demirkilic et al36 (Turkey)  Acute  Left thigh  Left pulmonary artery  Sternotomy (CPB)  15  Best37 (USA)  Acute  Right flank  Right atrium  Endovascular retrieval (snare) via right femoral vein  16  Bertoldo et al38 (Italy)  Acute  Right chest  Intracardiac IVC  Right thoracotomy to control IVC and Fogarty balloon via left femoral vein  17  Agarwal et al39 (India)  Acute  Right neck  Left inferior pulmonary artery  Left thoracotomy with arteriotomy  18  Kalimi et al40 (USA)  Acute  Right buttock  Internal iliac vein to right ventricle  Endovascular attempt → Sternotomy (CPB)  19  Chen et al41 (USA)  Acute  Right flank  Left inferior PA, right ventricle, atrio-caval junction  Endovascular retrieval (snare) via right IJ  20  Colquhoun et al42 (Scotland)  Acute  Right neck  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  Acute  Left groin  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  21  Bors et al43 (France)  Delayed (3 mo)  Left upper chest  Right ventricle  Sternotomy (CPB)  22  Hartzler44 (USA)  Acute  Left neck  Right ventricle  Endovascular retrieval (bioptome) via right IJ  23  Kaushik and Mandal45 (USA)  Acute  Left flank  Right atrium  Endovascular retrieval (basket) via right femoral vein  24  Headrick et al46 (USA)  Acute  Left epigastrium  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  25  Bining et al47 (Canada)  Acute  Right groin  Right ventricle  Sternotomy (CPB)  26  Lundy et al48 (USA)  Acute  Right chest  Right atrium  Observation  27  Lodder et al49 (Mpumalanga)  Acute  Right back  Left pulmonary artery  Observation  28  Van Arsdell et al50 (USA)  Acute  Hard palate  Right ventricle  Sternotomy (CPB)  29  Shannon et al51 (USA)  Acute  Right thigh  Inferior vena cava  Endovascular retrieval (basket) via left femoral vein  30  Nazir et al52 (Pakistan)  Acute  Back  Right ventricle/IVC  Endovascular retrieval (balloon)  31  Obermeyer et al53 (USA)  Acute  Left buttock  Right ventricle  Observation  32  Michelassi et al54 (USA)  Acute  Right abdomen  Right atrium  Sternotomy (CPB)  33  Nagy et al55 (USA)  Acute  Left flank  Right ventricle  Endovascular retrieval attempt then observation  34  Gandhi et al56 (USA)  Acute  Left shoulder  Right ventricle  Observation  Acute  Left lower extremity  Right ventricle  Observation  Acute  Right upper chest  Right ventricle  Observation  35  Patel et al57 (USA)  Acute  Right lower abdomen  Right atrium  Sternotomy WITHOUT CPB  Acute  Right flank  Left lung  Observation  Acute  Right mid-abdomen  Left lung  Endovascular retrieval (basket)  36  Stephenson et al58 (USA)  Acute  Lower abdomen  Left hilar area  Observation  Acute  Right upper arm  Left hilar area  Left thoracotomy  37  Bartlett et al59 (USA)  Acute  Right thigh/right suprapubic area  Right ventricle  Sternotomy (CPB)  38  Grewal et al60 (USA)  Acute  Left chest  Right ventricle  Sternotomy WITHOUT CPB  39  Fernandez-Ranvier et al61 (USA)  Delayed (2 wk)  Left thigh  Right pulmonary artery (middle lobe)  Endovascular retrieval attempt then observation  40  Ng et al62 (Hong Kong)  Acute  Anterior lower thorax  Pulmonary artery  Observation  41  Graham and Mattox63 (USA)  Acute  Right abdomen  Right ventricle  Thoracotomy/ventriculotomy WITHOUT CPB  42  Amsel et al64 (Belgium)  Acute  Right subclavian area  Right ventricle  Sternotomy (CPB)  43  Kortbeek et al65 (USA)  Acute  Abdomen  Pulmonary artery  Observation  44  Hussein et al66 (U.K.)  Delayed (10 yr)  Thigh  Right ventricle  Observation  45  Norton et al67 (USA)  Acute  Left buttock  Right ventricle  Thoracotomy/ventriculotomy with CPB  Acute  Right abdomen  Right ventricle  Sternotomy (CPB)  Acute  Periumbilical area  Right ventricle  Thoracotomy/atriotomy with CPB  46  Petsas et al68 (USA)  Acute  Right upper abdomen  Right pulmonary artery (lower lobe)  Thoracotomy/pulmonary arteriotomy  47  Soong et al69 (USA)  Acute  Chest (Left brachiocephalic vein)  Right ventricle  Sternotomy (CPB)  48  Quinn70 (USA)  Acute  Abdomen  Right ventricle  Thoracotomy  49  Gupta et al71 (USA)  Acute  Right iliac fossa  Right pulmonary artery (lower lobe)  None  50  Ezberci and Kargi72 (Turkey)  Acute  RUQ abdomen  Left lung (hilum)  Left thoracotomy pulmonary arteriotomy  51  Singer et al73 (USA)  Acute  Left chest  Left pulmonary artery → right pulmonary artery  Left thoracotomy → Endovascular retrieval attempt → Right thoracotomy  52  Jackson et al74 (USA)  Acute  Left chest  Left lower pulmonary lobe  Sternotomy (CPB) (bullet not retrieved)  53  Nally et al75 (USA)  Acute  Left arm  Right lower pulmonary lobe  Removed (no specific description how)  54  Gross et al76 (USA)  Acute  Right chest  Left lower lung lobe → Right pulmonary artery  Endovascular retrieval attempt → Endovascular retrieval attempt 1 mo later → CT surgery/IR combo procedure 1 wk later → Right thoracotomy with right lower lobectomy 8 wk after admission  #  Study  Timing of Diagnosis  Entry Site  Final Destination  Management  1  Breeding et al23 (USA)  Acute  Left neck (zone II)  Right ventricle  Sternotomy/endovascular retrieval (basket) via right common femoral vein  2  John and Edmondson24 (England)  Acute  Abdomen  Pulmonary artery  Thoracotomy/arteriotomy  3  O’neill et al25 (USA)  Acute  Abdomen  Right atrium  Endovascular retrieval (snare) via right IJ  4  Wales et al26 (England)  Delayed (4 yr)  Left chest  Right ventricle  Sternotomy (CPB)  5  Greaves et al27 (Scandinavia)  Acute  Left brachiocephalic vein  Right ventricle  Observation  6  Duke et al28 (USA)  Acute  Left globe  Left lower pulm lobe  Observation since critically ill  7  Pan et al29 (USA)  Acute  Abdomen  Infrarenal aorto-caval fistula → right ventricle  Sternotomy (CPB)  8  Hassan et al30 (USA)  Acute  Left chest  Left inferior pulmonary artery  Sternotomy (CPB)  9  Cysne et al31 (Brazil)  Acue  Right subclavian area  Right ventricle  Sternotomy (CPB)  10  Zenelaj et al32 (Albania)  Acute  Abdomen  Right ventricle  Left thoracotomy (without CPB)  11  Ettinger et al33 (Taiwan)  Acute  Right subclavian area  Right ventricle  “Ventriculotomy”  12  Padula et al34 (Brazil)  Acute  Right chest  Right ventricle  Sternotomy (CPB)  13  Wu et al35 (USA)  Delayed (14 yr)  Abdomen  Right ventricle  Right thoracotomy (CPB)  14  Demirkilic et al36 (Turkey)  Acute  Left thigh  Left pulmonary artery  Sternotomy (CPB)  15  Best37 (USA)  Acute  Right flank  Right atrium  Endovascular retrieval (snare) via right femoral vein  16  Bertoldo et al38 (Italy)  Acute  Right chest  Intracardiac IVC  Right thoracotomy to control IVC and Fogarty balloon via left femoral vein  17  Agarwal et al39 (India)  Acute  Right neck  Left inferior pulmonary artery  Left thoracotomy with arteriotomy  18  Kalimi et al40 (USA)  Acute  Right buttock  Internal iliac vein to right ventricle  Endovascular attempt → Sternotomy (CPB)  19  Chen et al41 (USA)  Acute  Right flank  Left inferior PA, right ventricle, atrio-caval junction  Endovascular retrieval (snare) via right IJ  20  Colquhoun et al42 (Scotland)  Acute  Right neck  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  Acute  Left groin  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  21  Bors et al43 (France)  Delayed (3 mo)  Left upper chest  Right ventricle  Sternotomy (CPB)  22  Hartzler44 (USA)  Acute  Left neck  Right ventricle  Endovascular retrieval (bioptome) via right IJ  23  Kaushik and Mandal45 (USA)  Acute  Left flank  Right atrium  Endovascular retrieval (basket) via right femoral vein  24  Headrick et al46 (USA)  Acute  Left epigastrium  Right ventricle  Endovascular retrieval attempt → sternotomy (CPB)  25  Bining et al47 (Canada)  Acute  Right groin  Right ventricle  Sternotomy (CPB)  26  Lundy et al48 (USA)  Acute  Right chest  Right atrium  Observation  27  Lodder et al49 (Mpumalanga)  Acute  Right back  Left pulmonary artery  Observation  28  Van Arsdell et al50 (USA)  Acute  Hard palate  Right ventricle  Sternotomy (CPB)  29  Shannon et al51 (USA)  Acute  Right thigh  Inferior vena cava  Endovascular retrieval (basket) via left femoral vein  30  Nazir et al52 (Pakistan)  Acute  Back  Right ventricle/IVC  Endovascular retrieval (balloon)  31  Obermeyer et al53 (USA)  Acute  Left buttock  Right ventricle  Observation  32  Michelassi et al54 (USA)  Acute  Right abdomen  Right atrium  Sternotomy (CPB)  33  Nagy et al55 (USA)  Acute  Left flank  Right ventricle  Endovascular retrieval attempt then observation  34  Gandhi et al56 (USA)  Acute  Left shoulder  Right ventricle  Observation  Acute  Left lower extremity  Right ventricle  Observation  Acute  Right upper chest  Right ventricle  Observation  35  Patel et al57 (USA)  Acute  Right lower abdomen  Right atrium  Sternotomy WITHOUT CPB  Acute  Right flank  Left lung  Observation  Acute  Right mid-abdomen  Left lung  Endovascular retrieval (basket)  36  Stephenson et al58 (USA)  Acute  Lower abdomen  Left hilar area  Observation  Acute  Right upper arm  Left hilar area  Left thoracotomy  37  Bartlett et al59 (USA)  Acute  Right thigh/right suprapubic area  Right ventricle  Sternotomy (CPB)  38  Grewal et al60 (USA)  Acute  Left chest  Right ventricle  Sternotomy WITHOUT CPB  39  Fernandez-Ranvier et al61 (USA)  Delayed (2 wk)  Left thigh  Right pulmonary artery (middle lobe)  Endovascular retrieval attempt then observation  40  Ng et al62 (Hong Kong)  Acute  Anterior lower thorax  Pulmonary artery  Observation  41  Graham and Mattox63 (USA)  Acute  Right abdomen  Right ventricle  Thoracotomy/ventriculotomy WITHOUT CPB  42  Amsel et al64 (Belgium)  Acute  Right subclavian area  Right ventricle  Sternotomy (CPB)  43  Kortbeek et al65 (USA)  Acute  Abdomen  Pulmonary artery  Observation  44  Hussein et al66 (U.K.)  Delayed (10 yr)  Thigh  Right ventricle  Observation  45  Norton et al67 (USA)  Acute  Left buttock  Right ventricle  Thoracotomy/ventriculotomy with CPB  Acute  Right abdomen  Right ventricle  Sternotomy (CPB)  Acute  Periumbilical area  Right ventricle  Thoracotomy/atriotomy with CPB  46  Petsas et al68 (USA)  Acute  Right upper abdomen  Right pulmonary artery (lower lobe)  Thoracotomy/pulmonary arteriotomy  47  Soong et al69 (USA)  Acute  Chest (Left brachiocephalic vein)  Right ventricle  Sternotomy (CPB)  48  Quinn70 (USA)  Acute  Abdomen  Right ventricle  Thoracotomy  49  Gupta et al71 (USA)  Acute  Right iliac fossa  Right pulmonary artery (lower lobe)  None  50  Ezberci and Kargi72 (Turkey)  Acute  RUQ abdomen  Left lung (hilum)  Left thoracotomy pulmonary arteriotomy  51  Singer et al73 (USA)  Acute  Left chest  Left pulmonary artery → right pulmonary artery  Left thoracotomy → Endovascular retrieval attempt → Right thoracotomy  52  Jackson et al74 (USA)  Acute  Left chest  Left lower pulmonary lobe  Sternotomy (CPB) (bullet not retrieved)  53  Nally et al75 (USA)  Acute  Left arm  Right lower pulmonary lobe  Removed (no specific description how)  54  Gross et al76 (USA)  Acute  Right chest  Left lower lung lobe → Right pulmonary artery  Endovascular retrieval attempt → Endovascular retrieval attempt 1 mo later → CT surgery/IR combo procedure 1 wk later → Right thoracotomy with right lower lobectomy 8 wk after admission  Figure 1 depicts number of patients by treatment group and location, with frequency of locations as follows: right ventricle (54.8%, n = 34), pulmonary arterial tree (32.3%, n = 20), right atrium (9.7%, n = 6), and intra-thoracic IVC (3.2%, n = 2). Most patients (88.7%, n = 55) were asymptomatic from the bullet emboli to the thoracic cavity. Those without signs or symptoms were either observed (27%, n = 15) or underwent an intervention (73%, n = 40). FIGURE 1. View largeDownload slide Overview of results. FIGURE 1. View largeDownload slide Overview of results. Table I lists the timing of diagnosis, entry site of the bullet, final destination of the bullet, and overall management. All but five of the patients were diagnosed acutely. Four patients had a documented bullet entry site in the neck (i.e., internal jugular veins), 18 in the chest (i.e., subclavian, brachiocephalic veins or superior/inferior vena cava), 22 in the back, flank or abdomen (i.e., inferior vena cava, renal or iliac veins), and 14 in an extremity or pelvis (i.e., axillary, brachial, iliac, or femoral veins). Seven of 62 patients (11.3%) demonstrated symptoms directly related to the cardiac venous emboli. Symptoms ranged from chest pain, dyspnea, or fever. Of these, four patients reported acute symptoms related to the missile embolus and all four patients underwent immediate open intervention successfully. Three patients presented with delayed symptoms (4–14 yr after initial injury) and TWO of these patients underwent successful retrieval via an open approach. The one symptomatic patient that was observed successfully presented 10 yr after his initial injury and reported no adverse sequelae. Of those patients with bullet emboli to the pulmonary arterial tree, 45% (n = 9) were observed; whereas, only 20% (n = 8) of patients with emboli to the right heart were observed. Most (92%, n = 57) patients were diagnosed acutely; whereas, 8% (n = 5) were diagnosed later. Of the five patients with a delayed diagnosis, 2 (40%) were discovered incidentally and 3 (60%) were discovered due to reported symptoms. Endovascular retrieval was successful in 53.3% (n = 8) of attempts. Of the seven initial endovascular attempts that failed, 28.6% (n = 2) were observed and 71.4% (n = 5) underwent open retrieval. Those who were asymptomatic and observed (n = 15) had no adverse sequelae during the reported follow-up. Lastly, in all of the reported cases, no mortalities were recorded and no complication rates were discussed. DISCUSSION Bullet emboli that enter the venous system most commonly migrate to the right heart. From the right heart, they may migrate to the pulmonary arterial tree. In 1987, Shannon et al,14 retrospectively reviewed 126 cases of venous bullet emboli and reported that 48% will lodge in the right heart, 36% will continue into the pulmonary circulation, and 16% will enter the peripheral/central veins. Our analysis supports this finding, demonstrating that the majority (64.7%) of venous emboli go to the right heart. The risk of paradoxic embolization to the arterial system is low. This usually occurs through a patent foramen ovale.14 Most foreign bodies that travel to the right ventricle will catch the chordopapillary apparatus of the tricuspid valve or the ventricular trebeculae.15 Indeed, most of the emboli were located in the right ventricle (58%).7,16–18 In a previous study by Michelassi et al,8 the authors identified several factors that contributed to the emboli’s destination. These factors include blood flow, body position, gravity, respiratory movements, and the missile’s caliber and weight. Historically, 70% of patients with venous bullet emboli are reportedly asymptomatic.5 Our review demonstrates nearly 90% of patients were asymptomatic; however, patients may present later with symptoms, in some cases months or years after the initial injury. The presenting symptoms are often signs of complications that need urgent intervention. Complications include valvular dysfunction, bacterial endocarditis, myocardial irritability, erosion of the bullet through the cardiac tissue, embolization to the pulmonary vasculature with resulting infarction and abscess formation, and “cardiac neurosis.”19–22 “Cardiac neurosis” refers to the anxiety reaction that a patient experiences after realizing that they have a bullet in their heart. The anxiety reaction can be characterized by fatigue, shortness of breath, rapid heartbeat, dizziness and other cardiac symptoms that are not caused by an actual disease of the heart. Shannon et al. conducted a review in 1987 of venous bullet emboli, which included 51 initially asymptomatic patients in whom missile emboli were not removed. When the projectile was not removed in these patients, 25% (13) of them developed complications and 6% (3) of them died.14 With today’s imaging modalities, the identification of the exact location of the bullet is often confirmed. However, further migration can occur. Adjuncts such as X-ray (Fig. 2), computed tomography (CT), transthoracic, and/or transesophageal echocardiography (TTE/TEE) may help establish the specific location. Once the fragment is located there are several options for management. FIGURE 2. View largeDownload slide Chest X-ray demonstrating a bullet embolus in the right heart (red arrow). FIGURE 2. View largeDownload slide Chest X-ray demonstrating a bullet embolus in the right heart (red arrow). Management options of venous bullet emboli include observation, endovascular extraction or open surgical retrieval. Open surgical intervention may include thoracotomy and sternotomy with or without cardiopulmonary bypass. The first report of an endovascular intervention for venous bullet emboli to the heart was in 1980 by Hartzler.77 Technical advancements in endovascular management since then have resulted in less morbidity and mortality.78 Our data do not fully account for the rapid advancement with interventional medicine (cardiology, radiology, or vascular surgery). Therefore, not all time frames reviewed included these more modern endovascular capabilities. A review of all the available literature over the course of 55 yr demonstrates the rate of successful endovascular retrieval (as the primary treatment) for all patients who underwent percutaneous intervention at 53%. Given the increased safety of endovascular intervention, some support the prophylactic retrieval of bullet emboli to avoid future complications.79 Removal of bullet emboli is safe with the availability of modern techniques (1–2% complication rate).14 When endovascular means alone are not sufficient, some authors have discussed a hybrid approach to remove the venous bullet emboli.4 The available data support the safety and efficiency of bullet emboli removal. However, while it may be safe to remove the bullet emboli, the need to remove it remains less clear. Some authors recommend that any bullet less than 5 mm, firmly lodged, and not causing arrhythmia or valvular dysfunction should not be retrieved.2,14,15 Observation can also be applied to patients who have bullets in the pulmonary tree that have no signs or symptoms concerning for pulmonary infarction, pulmonary abscess, or erosion in the bronchus.15 Those patients with cardiac emboli that become symptomatic should have the foreign body removed.14 From this review of the data, we propose the following algorithm. (Fig. 3) Patients with venous bullet emboli that exhibit symptoms should undergo retrieval. Endovascular extraction is an appropriate first-line treatment option when resources are available. If endovascular attempts fail, then open surgical retrieval should be considered. We also recommend that any patient with an atrial septal defect, ventral septal defect, or patent foraman ovale should undergo retrieval given the concern for stroke or distal emboli causing ischemia. A patient with asymptomatic emboli to the pulmonary artery can be observed; however, retrieval is recommended if the patient develops symptoms. FIGURE 3. View largeDownload slide Management algorithm for venous bullet emboli. FIGURE 3. View largeDownload slide Management algorithm for venous bullet emboli. If the bullet embolus is discovered in the right heart (atrium or ventricle) or central vein (IVC), we recommend an initial attempt at percutaneous retrieval unless the following criteria for observation are met: bullet <5 mm in diameter, smooth in appearance, firmly lodged, uncontaminated, and patient is hemodynamically stable without evidence of arrhythmias or valvular dysfunction. Patients with bullet emboli who meet these criteria can be safely observed and undergo serial imaging. In the event that the attempt at percutaneous retrieval from the right heart or central vein fails, we recommend that the patient then undergo open (sternotomy, thoracotomy) hybrid retrieval attempts. The surgical approach is determined by a combination of the location of the bullet and the surgeon’s preference. Most patients would require cardiopulmonary bypass as well. Bullet emboli discovered in the pulmonary arterial tree may be safely observed with serial imaging; however, if the patient develops symptoms (i.e., pulmonary infarction and abscess formation), then we recommend open retrieval of the foreign body. Percutaneous retrieval attempts have been associated with high failure rates and will likely lead to repeated procedures and resources in the management of pulmonary arterial bullet emboli. In all of the reported cases no mortalities were recorded. Most likely those that died from the initial injury, initial surgery, or during subsequent attempts at retrieval were not reported and the publication selection bias may be substantial. The lack of reported clinical follow-up is a major limitation for this review. There are several other limitations to this study. The removal of most cardiac emboli was performed without any symptoms or signs of injury. There are no randomized trials comparing leaving cardiac emboli in situ versus retrieving the foreign body. It is possible that many of the fragments could have been left in situ. Therefore, while a majority of cardiac emboli were retrieved, the evidence supporting retrieval is not backed by strong scientific research. However, the rate of symptoms (versus potential symptoms or potential complications) is most likely under-reported as the cardiac emboli were more often removed close to the time of diagnosis, thus preventing symptoms or complications from occurring. More studies are clearly warranted for this uncommon, but perplexing condition. Performing a review of retrospective data also lends itself to a selection bias since there is a tendency to report positive findings and discuss those patients who did well clinically. Additionally, there is the inherent risk of error in compiling or inputting data. We feel that the approach must be individualized to the patient’s specific clinical course; however, given the safety of modern technology and techniques, most patients should undergo intervention especially when the diagnosis of cardiac bullet embolus is made acutely. CONCLUSION Bullet emboli can prove to be a clinical challenge with removal made safer with the availability of modern techniques. Adjuncts such as X-ray, CT, transthoracic, and/or transesophageal echocardiography may help establish the diagnosis. The approach must be individualized to the patient’s specific clinical course, however most patients should undergo intervention. References 1 Gotsch KE, Annest JL, Mercy JA, Ryan GW: Surveillance for fatal and nonfatal firearm-related injuries – United States, 1993-1998. MMWR  2001; 50( SS02): 1– 32. 2 Rich NM, Collinsc GJ, Andersen CA, McDonald PT, Kozloff L, Ricotta JJ: Missile emboli. 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Google Scholar PubMed  77 Hartzler GO: Percutaneous transvenous removal of a bullet embolus to the right ventricle. J Thorac Cardiovasc Surg  1980; 80( 1): 153– 5. Google Scholar PubMed  78 Schroeder ME, Pryor HI, Chun AK, Rahbar R, Arora S, Vaziri K: Retrograde migration and endovascular retrieval of a venous bullet embolus. J Vasc Surg  2011; 53( 4): 1113– 5. Google Scholar CrossRef Search ADS PubMed  79 Miller KR, Benns MV, Sciarretta JD, et al.  : The evolving management of venous bullet emboli: a case series and literature review. Injury  2011; 42( 5): 441– 6. Google Scholar CrossRef Search ADS PubMed  Author notes The views expressed in this manuscript are those of the authors and do not reflect the official policy of the William Beaumont Army Medical Center, the Uniformed Services University of the Health Sciences, the Department of the Army, the Department of Defense, or the US Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

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Military MedicineOxford University Press

Published: Apr 6, 2018

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