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Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 105-106

Cardiac gunshot wound complicated by missile migration to the inferior vena cava

Department of Surgery/Unit of Cardiovascular and Thoracic Surgery, School of Medicine, Faculty of Medical Sciences, University of Sulaimani, Sulaymaniyah, Region of Kurdistan, Iraq

Date of Submission16-Aug-2020
Date of Acceptance30-Oct-2020
Date of Web Publication07-Aug-2021

Correspondence Address:
Prof. Abdulsalam Y Taha
Mamostayan District 112, Road 33, House 5, Postal Code Sulaimaniyah - 46001, P O Box-1155/64
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ais.ais_39_20

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How to cite this article:
Taha AY. Cardiac gunshot wound complicated by missile migration to the inferior vena cava. Arch Int Surg 2020;10:105-6

How to cite this URL:
Taha AY. Cardiac gunshot wound complicated by missile migration to the inferior vena cava. Arch Int Surg [serial online] 2020 [cited 2023 Dec 3];10:105-6. Available from:

Dear Editor

Bullet or missile embolism of the heart is exceedingly rare. Recently, we reported a case from Iraq[1] and thereafter, we received two emails from two colleague surgeons describing two previously unpublished cases from Iraq.

The first case was presented by Dr. Hisham H Hasan a cardiac surgeon from Mosel, Iraq. In his email correspondence of February 14, 2020 Dr. Hasan mentioned a patient with a bullet injury to the left ventricle which moved into the aorta and was subsequently retrieved from the left common femoral artery. Unfortunately, no further details were available.

The second case was summarized by Professor Dr. Azhar K Kassab a specialized Cardiothoracic & Vascular Surgeon in his email correspondence of February 24, 2020. Dr. Kassab wrote “In 1982, the second year of the Iraqi-Iranian war, a 35-year-old male Iraqi lieutenant colonel was referred to Ibn-Alnafis Hospital/Baghdad with a missile shell injury to the chest. Physical exam revealed a conscious patient with normal vital signs. There was a 2-cm entrance wound in the fourth inter-costal space close to the left sternal border with no exit. Plain chest X-ray (PA and lateral views) as well as angiography showed a 2 cm × 1.5 cm shell in the region of the right ventricle (RV). A decision was made to remove the shell. A repeat chest X-ray just prior to transferring the patient to the theater excluded shell migration”.

Dr. Kassab continued “Surgery was performed via a median sternotomy using cardiopulmonary bypass (CPB). There was a 2 cm wound at the anterior wall of the RV. The RV wound was enlarged and the surgeon's index finger was admitted into the RV cavity but the shell could not be felt. Unfortunately, a fluoroscopy was not performed because the operating table was not made from wood. The RV incision was then closed, CPB was terminated and sternotomy incision was closed. Postoperative plain X-ray showed the shell below the diaphragm. Angiography showed the shell inside the inferior vena cava (IVC) 5 cm distal to the diaphragmatic hiatus. A fluoroscopy was arranged the next day using an operating table made of wood. The sternum was re-opened. With the heart beating, a purse-string suture was placed in the right atrial (RA) appendage. The shell was then delivered using long artery forceps introduced through the RA appendage into the IVC. The postoperative period was smooth”.

Missiles lodged in the left ventricle or in the arterial tree (as in the first case) could migrate down into the arterial tree. The patients are commonly symptomatic and therefore removal of the bullet/missile is indicated to avoid the complications. Precise localization of the missile prior to surgical removal is mandatory as migration is common.[2]

Right ventricular bullet embolism (such as the second case) is an extremely rare phenomenon documented sporadically in the medical literature occurring most commonly in the setting of small caliber, low-velocity missiles/bullets.[3] Yoon et al.[4] searched the medical literature from 1960 to 2018 and identified a total of 62 patients with thoracic venous bullet emboli (n = 34, 54.8%) of them were located in the RV. Most such patients (n = 29, 85.3%) were asymptomatic. Open surgery was the main method of extraction of RV bullet emboli (n = 23, 67.6%). Endovascular techniques were used in three cases (8.8%), while seven cases (six asymptomatic) were just observed.

In Kassab's case, if the shell was not removed from the RV cavity, it could have moved to the pulmonary arteries or become complicated by endocarditis.[2] When the case was received, the only method of shell extraction was open surgery as endovascular techniques were relatively unknown four decades ago. However, extraction of the shell could have been performed in one session if fluoroscopy was available in the first operation. The retrieval of the shell by a long forceps introduced from RA appendage into the IVC was a smart method simulating endovascular techniques performed nowadays. Though Dr. Kassab apologized for having no photos of his patient, I should admire his excellent memory for the detailed description of the case and successful removal of the shell.


CPB: cardiopulmonary bypass, IVC: inferior vena cava, PA view: posteroanterior view, RA: right atrium, RV: right ventricle.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bakir DA, Othman YN, Taha AY. Pulmonary bullet embolism following cardiac gunshot wound: Case report of a bullet that traversed the heart twice. Cardiothoracic Surgeon 2020;28:5.  Back to cited text no. 1
Wojda TR, Dingley SD, Wolfe S, Terzian WT, Thomas PG, Vazquez D, et al. Foreign intravascular object embolization and migration: bullets, catheters, wires, stents, filters and more. In: Embolic diseases: unusual therapies and challenges. IntechOpen. 2017.  Back to cited text no. 2
Stallings LA, Newell MA, Toschlog EA, Thomas CC, Kypson AP. Right ventricular bullet embolism: Diagnostic and therapeutic decisions. Injury Extra 2013;44:64-6.  Back to cited text no. 3
Yoon B, Grasso S, Hofmann LJ. Management of Bullet Emboli to the heart and great vessels. Mil Med 2018;183:e307-13.  Back to cited text no. 4


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