Penetrating aortic injury left untreated for 20 days: a case report

Abstract

Background: Penetrating aortic trauma remains one of the most challenging injuries with a high mortality rate if left untreated, or if the surgical treatment is delayed. We present an uncommon case of a late diagnosed abdominal firearm injury, in which the bullet partially penetrated the wall of the aorta, creating a plug that prevented immediate death due to massive bleeding.

Case presentation: A 26-year-old Libyan man was a victim of a firearm wound, with a bullet penetrating his abdominal wall from the left to right side. After the assault, the victim, spent up to 20 days crossing the Mediterranean Sea to leave his country of origin. Abdominal radiography revealed the presence of a bullet located anteriorly to the second lumbar vertebra, while computed tomography angiography, unexpectedly, demonstrated that the bullet penetrated partially into the aortic wall at the level of the left renal artery. The bullet penetrated the aortic wall for half of its length, creating a plug that avoided immediate life-threatening bleeding at the time of the gunshot injury. The bullet was removed and the aortic lesion was repaired. The patient was discharged 6 days after the surgical procedure, in good health.

Conclusions: We presented a very rare case of late diagnosis of aortic injury caused by a gunshot lesion, in which the particular trajectory of the bullet helped avoid immediate life-threatening bleeding and, probably, saved the patient's life.

Keywords: Aorta; Aortic injury; Bullet; Firearm lesion; Gunshot injury; Late diagnosis; Penetrating trauma.

Fig. 1

Abdominal radiography in the lateral (a) and front (b) positions demonstrated the presence of a bullet located anteriorly to the second lumbar vertebra, with the tip rotated in the upright direction

Fig. 2

Abdominal computed tomography angiography demonstrated the presence of a bullet (arrow) partially penetrating the aortic wall at the level of the right renal artery (RRA) (a) close to the origin of the left renal artery (LRA), just below the superior mesenteric artery (*) (b)

Fig. 3

Abdominal computed tomography axial view demonstrating the significant injury to the body (a) and to the pedicle (b) and posterior arch of the lumbar vertebrae, supporting the opinion given that the vertebra dissipated the high velocity kinetic energy of the bullet

Fig. 4

The bullet after its extraction from the aortic wall