Acute total occlusion of the right coronary artery by a pellet.

A78-year-old man was hospitalized because of chest pain that had started 2 hours earlier while rifle shooting. On admission, he was alert and his vital signs were normal. Physical examination revealed no abnormalities, except for a wound at the jugular notch, presumably due to the entrance of a pellet. No exit wounds were found. The ECG showed marked ST-segment elevation in the inferior leads. Chest roentgenogram disclosed a radiopaque round foreign body, presumably a pellet, at the margin of the cardiac silhouette. Subsequent thoracic aortography showed no signs of extravasated blood, but coronary angiography showed amputation of the right coronary artery by the pellet (Figure). Removal of the pellet, percutaneously or surgically, was not attempted, because the patient was hemodynamically stable and because the risk of catastrophic hemorrhage was great. The patient experienced an uncomplicated inferior myocardial infarction and was discharged 10 days later with no ongoing problems.