Shotgun wound to the leg: strategies in managing acute arterial injury and bullet emboli to the heart and lungs

A 26-year-old man presented to the emergency department with an accidental self-inflicted shotgun wound to the posterior right thigh with a pulsatile bleed. On arrival, the heart rate was 154 bpm with no measurable blood pressure. After resuscitation with 2 L crystalloid and 1 unit packed red blood cells, the heart rate decreased to 102 bpm; the systolic blood pressure was 80 mmHg. Pedal pulses were palpable on the left; no Doppler signals were appreciated on the right. Given the large posterior thigh wound with buckshot visible at the entry site, a long-segment arterial injury was suspected. Vascular surgery was consulted and the left groin was accessed. An arteriogram revealed active extravasation from the right superficial femoral artery, with multiple contrast extravasation sites requiring two expandable covered stents. Completion angiography demonstrated cessation of extravasation with excellent distal flow. On the second postoperative day, the patient’s haemoglobin decreased from 10 to 7 g/dL. CT of the chest, abdomen and pelvis revealed metallic densities along …