Paradoxical arterial embolization of a missile via the pulmonary vein in a pediatric penetrating trauma patient

Abstract

Introduction: Paradoxical arterial embolization secondary to penetrating trauma from a gunshot wound (GSW) is a rarely described phenomenon that occurs when a missile crosses from the venous to arterial systemic circulation. There are few cases reported in the literature, and none in a preadolescent patient. Here we describe paradoxical arterial embolization from the pulmonary vein to the femoral bifurcation in a 5-year-old. Case report: A 5-year-old child presented after an accidental GSW to the right chest. The patient was hemodynamically stable on room air. The right lower extremity was pulseless, but without motorsensory deficit. Imaging was obtained which demonstrated a missile tract passing through the anterior chest wall and lung parenchyma toward the hilum. There was a small associated hemopneumothorax. The missile was found lodged distally in the right femoral artery bifurcation, having entered the arterial system via the pulmonary vein. The patient was transferred to a Level 1 trauma center and taken emergently to the operating room approximately 6 h post-injury where a right femoral artery cut-down was performed. A transverse arteriotomy was made and the missile was extracted. A thromboembolectomy catheter was passed distally where a small amount of thrombus was retrieved and retrograde flow was restored. There was excellent antegrade flow. The arteriotomy was closed primarily. Fasciotomies were not performed. A right chest tube was placed and a hemothorax was evacuated. The patient was admitted to the intensive care unit with palpable pedal pulses and treated with 48 h of systemic heparin. She developed no signs or symptoms of calf compartment syndrome. The chest tube was removed on post-operative day 3 and she was discharged home with no further medical therapy. Conclusion: Paradoxical arterial embolization secondary to a GSW is a rare entity, particularly in the pediatric population. Management of the ischemic limb is similar to that of any arterial embolization, and additional long-term medical therapy is unnecessary.