Ann Thorac Surg 2007;84:274-276
© 2007 The Society of Thoracic Surgeons
Case Reports
Coronary Embolization in Bullet Wounds: Role of Perioperative Coronary Angiography
Olivier Raisky, MD, PhD*,
Olivier Metton, MD,
Roland Henaine, MD,
Caner Salih, MD,
Jean-François Obadia, MD, PhD,
Jean Ninet, MD
Department of Cardiovascular Surgery, Hôpital Louis Pradel, Bron, France
Accepted for publication February 12, 2007.
* Address correspondence to Dr Raisky, Department of Cardiovascular Surgery, Hôpital Louis Pradel, 28 Ave du Doyen Lepine, Bron, Cedex 69677, France (Email: oraisky{at}yahoo.com).
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Abstract
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The management of patients presenting with signs of myocardial ischemia after a gunshot injury to the chest remains unclear. We report the case of 1 patient shot by a hunting weapon, presenting with clinical signs of tamponade and marked ST segment elevation. At the time of emergency exploration, no coronary lesions were seen. However, an emergency angiogram revealed acute occlusion of the right coronary artery by a pellet. Extraction was done on bypass. We believe that coronary angiography is necessary in case of pellet wounds to the chest presenting with signs of ischemia.
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Introduction
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Coronary embolization in bullet wounds is not so uncommon [1]. The route of the bullets is difficult to appreciate in thoracic shotgun patients. Based on the following case report, we tried to precise the diagnostic and treatment tree in this urgent situation.
A 40-year-old policeman was admitted after being shot by a hunting weapon of low ballistic range 4 hours earlier. He complained of severe chest pain. The shotgun pellets created wounds mainly to the anterior chest wall. On admission, clinical signs of tamponade were noted and he had circulatory collapse develop within 15 minutes.
On examination, no exit wounds were identified. The heart rate was approximately 120 beats/min with frequent arrhythmias. His blood pressure quickly dropped. The initial electrocardiogram showed marked ST segment elevation on leads II, III, and aVF and confirmed frequent ventricular arrhythmias. The chest roentgenogram disclosed three radio-opaque foreign bodies, presumed to be pellets at the margin of the cardiac silhouette. The troponin I level was 2.35 ng/mL (normal <0.2 ng/mL).
Urgent echocardiography revealed a circumferentially compressive hemopericardium. Ongoing hemodynamic deterioration necessitated the patient to be rushed to the operating room. The presumed diagnosis at this time was massive hemopericardium from a direct injury to the right coronary artery. At median sternotomy, the pericardial cavity was found to be full of fresh blood. Although cardiovascular stability was obtained rapidly with clot evacuation, signs of inferior ischemia with frequent ventricular arrhythmias persisted.
Examination of the heart and the pericardium revealed two wounds: one on the free wall of the right ventricle, close to, but not affecting the acute marginal branch of the right coronary artery. The second lesion entered the pericardium just above the phrenic nerve at the level of the superior vena cava and went through the anterolateral side of the ascending aorta. No exit wound was found and the aorta was not bleeding.
In view of the persistent electrocardiogram, evidence of acute inferior myocardial ischemia was found and an urgent coronary angiography was performed in the catheterization laboratory after routine chest closure.
Cardiac catheterization (Fig 1A) revealed no signs of extravasated blood, but it did show a pellet in the mid portion of the right coronary artery leading to total occlusion of the lumen with associated proximal thrombus. A further pellet was located in the trabecular septum.
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Fig 1. (Left) Coronary angiography after emergency treatment of the pericardial effusion showing an acute occlusion of the right coronary artery by pellet embolization and formation of a clot. (Right) Coronary angiography after removal of the pellet showing a normal coronary tree.
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Therefore the patient was taken back to the operating room and cardiopulmonary bypass was established in a standard manner, the aorta was cross clamped, and antegrade cold cardioplegia was given to arrest the heart. The pellet was not visible to inspection, but finger palpation of the right coronary artery permitted to localization. The pellet and associated thrombus was extracted through a longitudinal arteriotomy, which was closed using a saphenous vein patch.
The total cross-clamp time was 20 minutes with a total right coronary ischemic time of 6 hours. Weaning from bypass was uneventful and with no inotropic requirement. Although the arrhythmias settled, the ST segment elevation persisted. The postoperative troponin peak level was 52. The electrocardiogram progressed to Q waves in the inferior leads, and echocardiography revealed a small area of decreased inferior wall motion. The patient had an uneventful postoperative course and was discharged home on day 10. Postoperative coronary angiography revealed complete revascularization of the right coronary artery territory (Fig 1B). The patient remains symptom free at 2-year follow-up.
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Comment
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Our initial hypothesis as to the cause of the hemopericardium by direct injury to the right coronary artery was wrong, nevertheless, considering the unstable hemodynamic status, urgent sternotomy was probably the best option to treat the tamponade and to control any bleeding. An alternative option could have been to drain the pericardial effusion through a subxiphoid approach, allowing stabilization of the hemodynamics before coronary angiography. Based on our experience with this patient, and previous published data [1], we believe that coronary angiography is mandatory at the time of presentation for any patient with pellet wounds to the chest and signs of ischemia on electrocardiogram. It would have been more efficient for the angiogram to be performed in the operating room; however, this facility was not available to us at the time. This has been subsequently addressed.
We hypothesize that the pellet that lodged into the coronary was the same one that penetrated the aorta, because no exit wound from the aorta was found and no systemic pellet embolization was seen.
Penetrating bullet wounds are known to cause vascular embolization, especially when they are of low velocity, of small caliber [2], and have penetrated the chest [3, 4]. Migration and embolization are a frequent natural evolution of bullets and removal to prevent ischemic injuries, and secondary embolization is usually recommended [5]. When the coronary angiography showed the acute occlusion of the right coronary artery, we decided to remove the pellet to reperfuse the inferior wall. One could argue that the ischemic time was already approximately 5 hours at this point, and that because the infarction was well tolerated, the situation could have been managed conservatively after drainage of the pericardium [6, 7]. We decided to adopt a more aggressive approach to try to reduce the size of the infarction and also the possibility of further extension of the clot above the pellet with complete occlusion of the right proximal coronary.
Although removal seemed to be a better option to us than an arterial graft for a young patient, another approach could have been a "blind" graft at initial exploration to reduce the ischemic time, even if it was necessary to take the graft down later.
Our cardiologist did not feel that attempts at percutaneous removal were a good option. In the presence of frequent arrhythmias, the long segment of the clot and the difficulties in localizing the pellet on a beating heart, we believe that an off-pump approach would have been inappropriate. Removal of this pellet was technically easy and probably reduced the size of the infarction even if the reperfusion was late.
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References
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- Nerantzis CE, Konstantopoulos EK, Agapitos EB, Margaris NG, Gribisi JE. Acute occlusion of the left anterior descending coronary artery by shotgun pellets Am Heart J 1993;126:452-453.[Medline]
- Shannon JJ, Vo NM, Stanton Jr PE, et al. Peripheral arterial missile embolization: a case report and 22-year literature review J Vasc Surg 1987;5:773-778.[Medline]
- Trimble C. Arterial bullet embolism following thoracic gunshot wounds Ann Surg 1968;168:911-916.[Medline]
- Wallace KL, Slovis CM. Hepatic vein bullet embolus as a complication of left thoracic gunshot injury Ann Emerg Med 1987;16:102-104.[Medline]
- Symbas PN, Harlaftis N, Waldo WJ. Penetrating cardiac wound: a comparison of different therapeuticc methods Ann Surg 1976;183:377.[Medline]
- Hopkins HR, Dragan PP. Bullet embolization to a coronary artery Ann Thorac Surg 1993;56:370-372.[Abstract]
- La Vecchia L, Rubboli A, Paccanaro M, Varotto L, Fontanelli A. Acute total occlusion of the right coronary artery by a pellet Circulation 2001;104:e40.[Medline]
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Abstract
Introduction
