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) and
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):164
Part
II - WHAT ACTUALLY HAPPENED After
discussion, the decision was to limit surgical treatment to the popliteal AVF
and to follow up the patient's general and pulmonary evolution at one, two, three
and six months, and then annually.
On May 13, 1972, the patient underwent
surgical treatment of popliteal AVF, which consisted of venorrhaphy (the patency
of the popliteal vein was maintained) and of and of end-to-end interposition of
a segment of the greater saphenous vein to the popliteal artery (Figure 4).  Figure
4 - Access used for surgical correction of the arteriovenous fistula.
Tonoscillography, a common exam at that time, was used to verify the postoperative
outcome. This exam allowed comparing the flow before and after the surgery, and
the results were recorded on a disc. A postoperative arteriography showed patency
of the vein graft interposed in the popliteal artery.
In 1987, 15 years
after the trauma, a plain PA and lateral chest x-ray was performed in order to
assess the outcome, and the same metallic image was observed. Pulmonary artery
occlusion was not seen on selective arteriography and right femoral arteriography
revealed a patent vein graft with ectasia.
The conclusion is that the
surgical treatment of the AVF provided excellent results and that the decision
of not treating the pulmonary artery surgically was satisfactory since, during
this period, no clinical or local disorders were detected.
The patient continued
to be followed up and no complaints were reported.
In 2001, 30 years
after the accident (1971 / 2001), the patient was once again submitted to a new
evaluation, now with modern diagnostic methods, with the aim to assess his clinical
and surgical evolution during 30 years.
The evaluation methods were as
follows:
" PA and lateral chest x-ray, with the same radiological
aspect of previous exams;
" echocardiogram without alteration of
heart parameters and Doppler ultrasound of popliteal vessels, showing patency
of the vein graft;
" computed tomography angiography of the lungs
(Figure 5);
" digital arteriography via femoral catheterization
(Figure 6). Figure
5 - Computed tomography angiography of the chest showing the metallic fragment
in the same initial situation and the pulmonary artery without thrombosis. 
Figure
6 - Femoral arteriography showing patency of the popliteal artery and ectasia
of the vein graft made 30 years ago. 
FINAL
REMARKS AND CONCLUSIONS By
analyzing the results of the treatment and the patient's evolution at the ages
20 (1971), 35 (1987) and 50 (2001) years, we may say that he did not show, at
any time, symptoms or signs of pulmonary infarction or of pulmonary artery hypertension;
the correction of the arteriovenous fistula kept the patency of the artery and
vein during 30 years; the greater saphenous vein graft showed ectasia and presented
wall alterations compatible with atheromatous plaques consequent to arterialization.
The decision of not performing surgery on the pulmonary artery for removal
of the metallic object (projectile), allowed the patient to lead a normal life,
with no complications related to the presence of the foreign body. The patient
could go on with his professional, leisure and social life; clinical and surgical
observations on his evolution during a 30-year period (1971/2001) were made.
ACKNOWLEDGMENTS
This puzzling
clinical case was diagnosed, surgically treated and followed up by the author
during 30 years, with the invaluable contribution made by vascular surgeon Marcio
Leal de Meirelles and also by peer clinicians, cardiologists, radiologists, echographers
and hemodynamics specialists, especially Bartolomeu Burlamarqui, Mário
Salles Neto, Edson Saad, Heraldo Belmont Rosas, Francisco Cardoso, L. P. Brito-Lyra,
Carlos C. S. Peixoto and Lúcia Maria Monteiro da Silva, who guided and
performed several specialized exams between 1971 and 2001. We would like to express
our warmest thanks to all these professionals.
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