Embolization
of firearm projectile from the popliteal vein to the pulmonary artery:
follow-up and evolution during 30 years
(Portuguese
PDF version)
Coordinated
by Dr. Fausto Miranda Jr
Antonio
J. Monteiro da Silva*
*
Member of the Brazilian Society of Angiology and Vascular Surgery (SBACV)
Emeritus Member of the Brazilian College of Surgeons (CBC). Head professor,
Carlos Chagas Medical Graduate Institute - Rio de Janeiro. Director
of the Center for Vascular Therapeutics (CTV), Instituto Professor Monteiro
da Silva, Health Services - Rio de Janeiro.
Correspondence:
Dr. Antonio J. Monteiro da Silva
Praça Niterói, 24
CEP 20511-040 - Rio de Janeiro - RJ
Tel.: +55 21 2568.4452
E-mail: monteirosilva@aol.com
and monteirosilva@terra.com.br
J Vasc
Br 2003;2(2):149-50
A 20-year-old
patient was accidentally shot by a firearm projectile, .22 caliber,
in the right popliteal region. The patient received primary care at
the Emergency Room on July 22, 1971. Vascular exploration was not performed
at that time.
After five months, on December 26, in that same year, the patient was
admitted to the Division of Vascular Surgery.He complained of a mass,
at the site of the trauma, which "trembled" and "pulsated,"
implying that he had a "heart" behind his knee (sic).
On examination, a thrill was detected, which suggested posttraumatic
arteriovenous fistula (AVF) of right popliteal vessels. Based on this
diagnosis, the surgical correction of AVF was proposed.
On preoperative examination, the posteroanterior and lateral chest x-ray
surprisingly revealed a radiopaque foreign body, probably metallic,
in the left lung (Figure 1).
Figure
1 - Posteroanterior and lateral x-ray showing a metallic fragment in
the pulmonary hilum.
There
was no scar on the chest wall that could suggest a gunshot wound. For
clarification, several x-rays of various parts of the body were taken,
from the skull to the feet, but no other images of a metal object were
observed.
Selective arteriography was requested and performed through catheterization
of the pulmonary artery at the State Institute of Radiology, showing
"a metallic foreign body, possibly a firearm projectile, located
inside the left pulmonary artery branch" (Figure 2).
Figure
2 - Pulmonary arteriography showing the pulmonary artery without thrombosis
and with a metallic fragment in a branch.
The exams
led to the conclusion that the projectile suffered embolization from
the popliteal vessels, migrating from the popliteal vein to the left
pulmonary artery, having made, therefore, "a fantastic journey."
When the projectile reached the popliteal vessels, it damaged the popliteal
artery and vein, entered the vein, was conducted through the femoral
vein, iliac vein, inferior vena cava, passed into the right atrium,
the right ventricle and finally lodged itself in a branch of the left
pulmonary artery, without causing obstruction.
An arteriography via femoral artery puncture was performed in order
to determine popliteal AVF. It clearly showed the immediate reflow of
the contrast medium through the popliteal vein, characterizing AVF.
An adjacent pseudo-aneurysm was also present (Figure 3).
Figure
3 - Femoral arteriography showing the arteriovenous fistula between
the left popliteal artery and vein.
As at
that time (1971) this was a sui generis case, representing a true therapeutic
challenge, before indicating the surgical correction of popliteal AVF,
those in charge of the clinical case gathered vascular, heart and chest
surgeons in a "medical conference" to decide on the treatment
of the foreign body (projectile) inside the left pulmonary artery branch.
The pros and cons of a surgical intervention in the pulmonary region
were discussed. Among the observations made, the fact that the patient
did not present, on any occasion, clinical alterations related to the
presence of the foreign body in the pulmonary artery or in the pulmonary
region (pain, dyspnea, pulmonary infarction, shock, etc.) was of note.
This showed that no clinical aggression was felt by the patient. They
also considered that there were technical, structural and supportive
restrictions on chest surgery at that time (1972).
