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Asheville Radiology Associates Asheville, NC 28802
In their recent report, in which they describe embolization of a bullet to the carotid artery, Duncan and Fourie [1] state that initial examination of the patient failed to reveal evidence of cardiac injury. They suggest that the course of the bullet took it through the right ventricle and interventricular septum.
Several years ago, a patient in our hospital presented with an ischemic left leg after receiving a gunshot wound in the chest. The wound was not near the heart. Diagnostic angiography revealed embolization of the bullet to the left common femoral artery, and the bullet was surgically removed. It was postulated that the bullet had entered a pulmonary vein and subsequently traversed the left atrium and left ventricle on its way to the leg.
Despite the wound's apparent proximity to the heart in the case described by Duncan and Fourie, the absence of cardiac injury would suggest that their bullet might have followed a similar intravascular course. Direct passage through the substance of the heart would not be necessary.
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Unitas Interventional Unit Lyttelton, 0140, South Africa
We thank Dr. Braun for his comments concerning the postulated alternative mechanism of entry of the bullet into the systemic circulation via the pulmonary venous system in the case we described [1]. We decided that a transcardiac route had been taken by the bullet on the basis of the position of the entrance wound and the lack of evidence of damage to the lungs on thoracic radiography—either in the form of any visible pulmonary contusion or of a pleural air or fluid collection. Unfortunately, no sectional thoracic imaging, which may have proven more sensitive at confirming or excluding a transpulmonary passage of the bullet, was performed at initial admission. We also did not have the benefit of surgical exploration of the thorax.
Altough direct evidence of cardiac penetration is lacking in our case, we still believe, on the basis of the available evidence, that this was the more likely route of the bullet. However, we do accept the mechanism of injury postulated by Braun as an alternative one, raising the issue that a more thorough investigation by CT imaging of the thoracic entrance-wound region should possibly have been performed at the time of presentation, despite the normal appearance of the chest radiograph and lack of clinical cardiopulmonary abnormalities.
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