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Transmediastinal gunshot wounds are infrequent but life-threatening injuries. The course of the projectile and the bullet track often is unpredictable. Prompt and specific diagnostic and therapeutic interventions are necessary to quickly identify and repair potentially life-threatening injuries to the heart, great vessels, and the aerodigestive tract. Multiple diagnostic algorithms exist for work-up of these injuries, and the therapeutic interventions are diverse and challenging. We describe a patient with total mediastinal traverse, who presented with right-sided hemopneumothorax. The work-up revealed surprisingly an isolated left internal mammary artery transection with a significant hemorrhage that mandated surgical intervention in left chest.

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