Intravascular missile embolization in childhood: report of a case, literature review, and recommendations for management.

A collective review of 20 cases of missile embolization among children (1961 to 1988) is analyzed, one case added, and guidelines for diagnosis and management are outlined. Causative agents were bullets (14 patients), pellets (5), and fragments (2). Their trajectory was arterioarterial (11), venovenous (5), paradoxical (4), and mixed (1). Diagnosis was suspected when an exit wound was absent and the foreign body was traced on regional x-ray. Embolization was predominantly to the legs, with a tendency for the left (5 of 8 cases). Upper extremity emboli were exclusively to the right. Only one of five cardiac entries required closure to control bleeding compared with four of six aortic. Embolectomy was performed in 16 patients. The overall mortality rate was 9.5%. Factors predicting a favorable outcome are early presentation, diagnosis, and intervention; location of cardiovascular entry and embolus site; and presence of soft tissue tamponade at entry wound. Although embolectomy for cerebral, asymptomatic pulmonary arterial, and silent venous emboli is controversial, universal agreement prevails regarding removal of systemic arterial as well as venous emboli that are potentially problematic.