Intravascular bullet embolization: a multicenter three-case series and literature review.

Introduction and importance: Intravascular bullet embolization (IBE) is a rare but potentially life-threatening complication of penetrating trauma. It may present as either arterial or venous embolization and is most commonly associated with low-velocity, small-caliber gunshot wounds (GSWs). Diagnosis is often challenging, and management remains controversial because of the limited evidence available to guide therapeutic decision-making. Case presentation: We present a multicenter case series of three patients with venous bullet embolization treated using a hybrid endovascular-surgical approach. In all three cases, the projectile was successfully captured using endovascular techniques; however, definitive retrieval required a venotomy because of the projectile's diameter. All three patients had favorable clinical outcomes, with no procedure-related complications and complete functional recovery during follow-up. Clinical discussion: IBE should be suspected when the number of entry and exit wounds is inconsistent with the expected ballistic trajectory. Imaging studies play a pivotal role in confirming the diagnosis and in planning the therapeutic strategy. Although management remains controversial and should be individualized, advances in endovascular techniques have expanded the minimally invasive options for foreign-body retrieval. Our case series illustrates that although endovascular capture of the projectile may be technically feasible, definitive retrieval may still require a venotomy when the projectile's diameter precludes endovascular removal. Conclusion: IBE is a rare complication of penetrating trauma that requires a high index of clinical suspicion for timely diagnosis. When technically feasible and supported by appropriate expertise and resources, an endovascular approach may be considered as an initial retrieval strategy. Management should be individualized according to the type of embolization, projectile characteristics, anatomical location, the patient's clinical condition, and the anticipated risk-benefit balance of intervention.