Systematic review of civilian intravascular ballistic embolism reports during the last 30 years

Bullet and Shrapnel Embolism: When “Uncommon” Meets “Dangerous”

“…The reported distribution of BSE between venous, arterial, and cardiac portals of entry varies across published studies [4,20,21]. Nonetheless, clinical manifestations and management principles tend to be fairly consistent across the literature.…”

“…The incidence of shrapnel-related BSE may be even lower [4]. Projectiles from non-powdered guns, often regulated as recreational toys rather than weapons, can pose significant risk of embolization, with a recent systematic review calling attention to this public health risk in the pediatric population [20].…”

“…Projectiles can enter the cardiovascular system in a myriad of ways, including by direct entrance into an artery or vein, direct entrance into the chambers of the heart, or erosion from the lungs into the pulmonary vasculature [22]. According to a systematic review by Kuo et al [20], reporting on 261 cases of BSE, embolization via venous route is most common (56%), with arterial (27%) and cardiac injuries (15%) seen less frequently. It is imperative that physicians are able to recognize the signs and symptoms of BSE so that timely and appropriate care can be instituted, with the goal of minimizing both associated complications and mortality.…”

“…In a recent review of 261 cases of BSE by Kuo et al [20], authors propose a management strategy algorithm for intravascular projectiles, based on the evidence that foreign objects within the "left-sided" (e.g., left cardiac chambers, systemic arteries, pulmonary veins) circulation pose a greater risk of complications than those within the "rightsided" (e.g., right cardiac chambers, systemic veins, pulmonary arteries) circulation. Their algorithm considers the circulatory site (left vs. right), the presence or absence of symptoms, as well as presence of a cross-circulation shunt.…”

“…Their algorithm considers the circulatory site (left vs. right), the presence or absence of symptoms, as well as presence of a cross-circulation shunt. They propose that all missiles to the "left-sided" circulation be removed either by operative or endovascular routes, while objects within the "right-sided" circulation may be safely managed conservatively if the patient is asymptomatic and does not have a right-to-left shunt [20].…”