Hybrid treatment of bullet embolism at the abdominal aortic bifurcation, complicated with thoracoabdominal aorta pseudoaneurysm and common iliac artery occlusion: case report

Metzger, Patrick Bastos; Monteiro, Rafael Borges; Medeiros, Maria Luiza Leite de; Lima, Willian Guidini; Bertoldi, Vinicius; Rossi, Fabio Henrique; Izukawa, Nilo Mitssuru; Kambara, Antônio Massamitsu

doi:10.1590/jvb.2014.012

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Case Reports • J. vasc. bras. 13 (01) • Jan-Mar 2014 • https://doi.org/10.1590/jvb.2014.012 linkcopy

Hybrid treatment of bullet embolism at the abdominal aortic bifurcation, complicated with thoracoabdominal aorta pseudoaneurysm and common iliac artery occlusion: case report

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Embolization due to a firearm projectile entering the bloodstream is a rare event that is unlikely to be suspected during initial treatment of trauma patients. We describe and discuss a case of bullet embolism of the abdominal aortic bifurcation, complicated by a pseudoaneurysm of the thoracoabdominal aorta and occlusion of the right common iliac artery, but successfully treated using a combination of endovascular methods and conventional surgery.

gunshot wounds; embolism; aorta

Authorship

person Patrick Bastos Metzger

schoolInstituto Dante Pazzanese - IDPC, Centro de Intervenções Endovasculares - CIEV , São Paulo, SP, BrasilInstituto Dante PazzaneseBrasilSão Paulo, SP, BrasilInstituto Dante Pazzanese - IDPC, Centro de Intervenções Endovasculares - CIEV , São Paulo, SP, Brasil

person Rafael Borges Monteiro

schoolHospital Municipal do Campo Limpo - HMCL, Departamento de Cirurgia Vascular, São Paulo, SP, BrasilHospital Municipal do Campo Limpo - HMCLBrasilSão Paulo, SP, BrasilHospital Municipal do Campo Limpo - HMCL, Departamento de Cirurgia Vascular, São Paulo, SP, Brasil

person Maria Luiza Leite de Medeiros

schoolHospital Municipal do Campo Limpo - HMCL, Departamento de Cirurgia Geral, São Paulo, SP, BrasilHospital Municipal do Campo Limpo - HMCLBrasilSão Paulo, SP, BrasilHospital Municipal do Campo Limpo - HMCL, Departamento de Cirurgia Geral, São Paulo, SP, Brasil

person Willian Guidini Lima

person Vinicius Bertoldi

person Fabio Henrique Rossi

person Nilo Mitssuru Izukawa

person Antônio Massamitsu Kambara

Correspondence Patrick Bastos Metzger CIEV Av. Doutor Dante Pazzanese, 500 - Vila Mariana CEP 04012-909 - São Paulo (SP), Brasil E-mail:
patrickvascular@gmail.com

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Author's information PBM Médico Cirurgião Vascular e Endovascular do Hospital Municipal do Campo Limpo e do Centro de Intervenções Endovasculares (CIEV) do Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil. Título de Cirurgia Vascular e Endovascular pela Sociedade Brasileira de Cirurgia Vascular. Doutorando da Universidade do Estado de São Paulo - USP. RBM Chefe do Serviço de Cirurgia Vascular do Hospital Municipal do Campo Limpo. Cirurgião Vascular e Endovascular do Hospital Municipal do Campo Limpo. Título de Cirurgia Vascular pela Sociedade Brasileira de Cirurgia Vascular. WGL Médico Residente do Serviço de Cirurgia Geral do Hospital Municipal do Campo Limpo. MLLM Chefe da Residência de Cirurgia Geral do Hospital Municipal do Campo Limpo. Título de Cirurgião Geral e Videolaparoscopista pelo Colégio Brasileiro de Cirurgiões. VB Chefe da Diretoria Médica do Hospital Municipal do Campo Limpo. Chefe da Unidade de Terapia Intensiva do Hospital Municipal do Campo Limpo. FHR Médico Cirurgião Vascular e Endovascular do Centro de Intervenções Endovasculares (CIEV) do Instituto Dante Pazzanese de Cardiologia. Título de Cirurgia Vascular e Endovascular pela Sociedade Brasileira de Cirurgia Vascular. NMI Doutor, Chefe da Seção Médica de Cirurgia Vascular e do Centro de Intervenções Endovasculares do Instituto Dante Pazzanese de Cardiologia. Membro Titular da Sociedade Brasileira de Cirurgia Vascular. Título de Cirurgia Vascular e Endovascular pela Sociedade Brasileira de Cirurgia Vascular. AMK Doutor, Chefe da Seção Médica de Radiologia e do Centro de Intervenções Endovasculares do Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil. Membro Titular do Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR).

Author's contributions Conception and design: PBM, NMI, AMK, RBM Analysis and interpretation: PBM, RBM Data collection: PBM, RBM, MLLM, WGL, FHR Writing the article: PBM Critical revision of the article: PBM Final approval of the article*: PBM, RBM, MLLM, WGL, VB, FHR, NMI, AMK Statistical analysis: N/A Overall responsibility: PBM, RBM Obtained funding: None

SCIMAGO INSTITUTIONS RANKINGS

Instituto Dante Pazzanese - IDPC, Centro de Intervenções Endovasculares - CIEV , São Paulo, SP, BrasilInstituto Dante PazzaneseBrasilSão Paulo, SP, BrasilInstituto Dante Pazzanese - IDPC, Centro de Intervenções Endovasculares - CIEV , São Paulo, SP, Brasil

Hospital Municipal do Campo Limpo - HMCL, Departamento de Cirurgia Vascular, São Paulo, SP, BrasilHospital Municipal do Campo Limpo - HMCLBrasilSão Paulo, SP, BrasilHospital Municipal do Campo Limpo - HMCL, Departamento de Cirurgia Vascular, São Paulo, SP, Brasil

Hospital Municipal do Campo Limpo - HMCL, Departamento de Cirurgia Geral, São Paulo, SP, BrasilHospital Municipal do Campo Limpo - HMCLBrasilSão Paulo, SP, BrasilHospital Municipal do Campo Limpo - HMCL, Departamento de Cirurgia Geral, São Paulo, SP, Brasil

Figures

Figures (3)

Thumbnail

Figure 1 A) Tomography of the upper abdomen showing a projectile at the level of the 11th thoracic vertebra and a comminuted fracture of the vertebral body. B) Tomography of the abdomen 5 days after trauma showing that the bullet had migrated to the level of the fifth lumbar vertebra, in the aortic bifurcation topography. C) Angiotomography 5 days after trauma showing a thoracoabdominal pseudoaneurysm. D) Angiotomography showing occlusion of the right common iliac artery and filling of the external iliac artery.

Thumbnail

Figure 2 A) Digital subtraction arteriography showing a thoracoabdominal pseudoaneurysm approximately 2 cm from the celiac trunk. B) Results of endovascular treatment with an S- TAG endoprosthesis, achieving total occlusion of the pseudoaneurysm. C) Aortoiliac arteriography after placement of covered stent on right and self-expanding stent on left. Note the occlusion visible on the right and the negative image, suggestive of thrombus in the stent placed in the left common iliac artery.

Thumbnail

Figure 3 A) Surgical isolation of the aortic bifurcation. B) Aortotomy, removal of bullet and removal of stents. C) Primary arteriography of the abdominal aorta. D) Self-expanding and covered stents. Note the presence of thrombi adhering to the mesh of the self-expanding stent. E) Firearm projectile removed from the aorta. Note, in the detail, the flattened shape of the bullet which prevented its removal via the iliac-femoral segment (front view).

imageFigure 1 A) Tomography of the upper abdomen showing a projectile at the level of the 11th thoracic vertebra and a comminuted fracture of the vertebral body. B) Tomography of the abdomen 5 days after trauma showing that the bullet had migrated to the level of the fifth lumbar vertebra, in the aortic bifurcation topography. C) Angiotomography 5 days after trauma showing a thoracoabdominal pseudoaneurysm. D) Angiotomography showing occlusion of the right common iliac artery and filling of the external iliac artery. open_in_new

imageFigure 2 A) Digital subtraction arteriography showing a thoracoabdominal pseudoaneurysm approximately 2 cm from the celiac trunk. B) Results of endovascular treatment with an S- TAG endoprosthesis, achieving total occlusion of the pseudoaneurysm. C) Aortoiliac arteriography after placement of covered stent on right and self-expanding stent on left. Note the occlusion visible on the right and the negative image, suggestive of thrombus in the stent placed in the left common iliac artery. open_in_new

imageFigure 3 A) Surgical isolation of the aortic bifurcation. B) Aortotomy, removal of bullet and removal of stents. C) Primary arteriography of the abdominal aorta. D) Self-expanding and covered stents. Note the presence of thrombi adhering to the mesh of the self-expanding stent. E) Firearm projectile removed from the aorta. Note, in the detail, the flattened shape of the bullet which prevented its removal via the iliac-femoral segment (front view). open_in_new

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