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

Authors: Alessia GiaquintaDovile MociskyteGiuseppe D’ArrigoGiuseppe BarbagalloFrancesco CertoMassimiliano Veroux & Pierfrancesco Veroux 

Case presentation


A 26-year-old Libyan man was a victim of a firearm wound while he was running seeking for refuge, with a bullet penetrating his abdominal wall from the left to right side, with an entrance orifice of approximately 3 cm in diameter at the left lumbar paravertebral region. No exit wound was seen. After the assault, the victim, a clandestine refugee from Libya, spent up to 20 days crossing the Mediterranean Sea to leave his country of origin. He was finally admitted to a recovery center in Italy and then to a local hospital, in good general condition and with no signs of hemodynamic shock.

Abdominal radiography revealed the presence of a bullet located anteriorly to the second lumbar vertebra, with the tip rotated in the upright direction and fractures of the second and third lumbar vertebrae (Fig. 1). Subsequently, the patient was immediately transferred to the department of neurosurgery of our hospital. At admission, he was hemodynamically stable, with a stable hemoglobin value (10.1 g/dl), a Glasgow Coma Scale of 15, and with lumbar pain, hyposthenia, and hyperesthesia of the left lower limb. Preoperative computed tomography (CT) angiography, unexpectedly, demonstrated that the bullet penetrated partially into the aortic wall at the level of the left renal artery, without any signs of active blood loss or surrounding hematoma (Figs. 2, 3).

Figure 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

Figure 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)
FIgure 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

The patient was immediately scheduled for surgical repair of the aortic injury. The aorta was accessed retroperitoneally through a left lobotomy. The abdominal aortic segment was entirely exposed by a retrorenal access and section of the fibers of the left pillar of the diaphragm and then isolated before dealing with the bullet. At the level of the left renal artery, a bullet partially penetrating the left latero-posterior aortic wall was visualized. The bullet crossed the lumbar spine, fragmenting the second and third lumbar vertebrae, and finally 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.

There were no signs of visceral injury or surrounding hematoma. After clamping of the aorta and the left renal artery, the bullet was clearly visible on the posterior surface of the aorta, just behind the left renal artery (Video 1). Subsequently, it was removed and the aortic lesion was repaired by a 5–0 polypropylene running suture. The extracted bullet was about 27 mm in length, with a spritzer (pointed) nose, resembling a military rifle cartridge (Fig. 4). The surgical intervention was completed by the neurosurgery team by using spinal fixation with pedicle screws at the level between the second and fourth lumbar vertebrae. The immediate postoperative course was uneventful, and computed tomography angiography performed on postoperative day 3 did not demonstrate any sign of aortic bleeding and showed good results of the spinal fixation. Consequently, the patient was discharged 6 days after the surgical procedure, without any neurological symptoms.

Video 1. After clamping, the aorta was dissected and the bullet was clearly visible on the posterior surface of the aortic wall. (M4V 2928 kb)

Figure 4. The bullet after its extraction from the aortic wall
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