Venous Fragment Embolism to the Pulmonary Artery: A Rare Occurrence

Despite the large number of gunshot wounds treated in civilian and military practice, embolization of missiles to the pulmonary artery is relatively uncommon. In a review of 7,500 medical reports from casualties from the Vietnam Vascular Registry, only 22 patients with known vascular trauma had missile emboli (0.3%), and of those, only 4 (.0005%) were to the pulmonary artery. Causative agents of missile embolism are numerous and are often a considerable diagnostic and therapeutic challenge. We believe this is the first reported case clearly demonstrating venous fragment embolus to the pulmonary artery from the lower extremity, specifically the popliteal vein using x-rays preand post-migration. The fragment was created when a ground-fired rifle bullet shattered the inferior nose bubble of a military helicopter, and a mixture of material was subsequently introduced into the popliteal fossa of the navigator. We also offer a review of the literature and introduce an algorithm for the workup and management options of missile emboli.