Radiological Case: Inferior Vena Cava Bullet Retrieval

Danesh Bansal, MD; Patrick Hussey, MD; Ignacio Chiong, MD

Disclosures

Appl Radiol. 2019;48(1):48D-48E. 

In This Article

Imaging Findings

Serial imaging demonstrated a wandering bullet within the inferior vena cava (IVC).

An initial trauma chest radiograph revealed a large right hemothorax requiring chest tube placement. Subsequent CT angiogram of the chest demonstrated that the bullet originated in the right upper chest, traversed inferiorly into the thoracic cavity, and terminated dependently within the right atrium (Figure 1). Associated injuries included a right, second-anterior-rib fracture, right upper-lobe contusion, and large right hemothorax. A chest radiograph obtained 2 hours after presentation to verify central line placement did not show a bullet overlying the right atrium. A consequent abdominal radiograph illustrated a metallic foreign body overlying the right L1 paraspinal area, concerning for bullet migration (Figure 2).

Figure 1.

A CT angiogram of the chest demonstrates a bullet within the dependent aspect of the right atrium.

Figure 2.

Abdominal radiograph depicts a metallic foreign body overlying the right L1 paraspinal area, suggesting caudal migration of the bullet fragment from the right atrium.

A contrast-enhanced CT performed 4 hours later validated the bullet within the IVC at the level of the renal veins, consistent with caudal migration (Figure 3). Given the wandering nature of the bullet, the patient was taken to interventional radiology for retrieval. Angiographic images through a 16 French hemostatic sheath placed via a left common femoral vein approach established a patent left common iliac vein and IVC with cranial migration of the bullet, now residing at inferior cavoatrial junction. Through the hemostatic sheath, a cloverleaf snare device was used to grasp and retract the foreign body into the left common femoral vein (Figure 4). The sheath was subsequently removed and a small skin incision was made alongside the snare device in the left inguinal region. A hemostat was used to dissect the subcutaneous tissues and remove the bullet. The patient tolerated the procedure well without complications.

Figure 3.

Contrast-enhanced CT demonstrates the bullet within the IVC at the level of the renal veins.

Figure 4.

(A, B) Angiographic images display a foreign body at the inferior cavoatrial junction encompassed by a cloverleaf snare device and subsequently retracted into the left common iliac vein.

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