Introduction

Foreign bodies in the heart or major arteries can be seen due to fire gun injuries. Increased use of illegal drugs in recent years can cause migrating needles¹,². Furthermore, the catheters used for intravascular treatment can sometimes break off and they can go to distal arteries or can migrate to the heart if they in veins³,⁴.

The sources of intravascular foreign bodies are different in every age group. The most common cause in children is iatrogenic, while in adults, it is due to illegal drug use or war injuries⁵.

Foreign body embolies that origin arterial system have mostly seen symptomatic and that’s why they require emergency surgery. However, asymptomatic cases are followed conservatively, they can cause vascular related end-organ pathologies as time passes⁶.

In this paper, we present the case of a 10-year-old male patient who got injured by a fire gun and underwent emergency surgery. The bullet was not founded in the intrathoracic region, the bullet had migrated into the segmental artery of the liver.

Case report

A 10-year-old male patient applied to the emergency service. The first physical examination shown the entrance of the bullet was just below the right nipple, however, there were no evidence of an exit of the bullet (Fig. 1). His heart rate was 138 beats/min, blood pressure was 65/38 mmHg. Echocardiography was performed in the emergency room.

Figure 1 Entrance wound of bullet. 

The right ventricular dilatation, dilatation of the inferior vena cava, and signs of cardiac tamponade supported by more than 2.8 cm of fluid at the thinnest point around the heart were observed. He underwent emergency operation immediately. After the pericardium was opened, his vital functions immediately returned to normal. However, no major bleeding was found. No signs or traces of the bullet were found. During intraoperative exploration, a bullet entrance was found on the right pleural area (Fig. 2).

Figure 2 Bullet wound on pleura. 

When explored in detail, adventitial hematoma was detected on the right anteromedial surface of the aortic root (Fig. 3). No additional bleeding was detected despite physical manipulations and washing with warm water. After the procedure, chest and abdomen computed tomography were applied in addition to the chest X-ray. A foreign body forming a metallic structure was detected in the segmental branch of the hepatic artery (Fig. 4). With the recommendations of the pediatric surgery department, no additional surgeries should be planned, and the patient was decided to be followed. After the 5^th day postoperatively, no pathologies were seen in the patient’s liver functions tests, so the patient got discharged without any problem.

Figure 3 Adventitial hematoma on aortic root. 

Figure 4 Chest X-Ray and CT images of the bullet that migrated to hepatic system. 

Discussion

Foreign body embolization was first introduced in literature in 1834, after that, only a few cases have been added to literature⁷. If the foreign body is not found at the site of surgery, foreign body embolization should always be kept in mind⁸.

Gunshot wounds manifesting in the intravascular space affect the arterial system 4/1 more frequently. When a foreign body enters the arterial lumen, the probability of causing ischemic damage is 80%⁸,⁹.

In symptomatic cases and if the diameter of the foreign body is more than 5 mm, emergency surgery should be planned to prevent ischemic event². The treatment of asymptomatic foreign body penetrations is still not very clear. Foreign body excision or conservative treatment options should be considered according to the risk of surgery and complications¹⁰.

Conclusion

Foreign body migration from the ascending aorta to the end-organ artery is a very rare in literature after a fire gun injury. Symptomatic cases, emergency surgery should be planned immediately. In asymptomatic cases, the risks and benefits should first be considered before any surgical approach.