foreign body embolism from an injured vein to the right ventricle has been reported by several authors . we report the case of embolism of a bullet from injured inferior cava vein ( icv ) in a young man . a 32 years old patient was admitted in the emergency department after a right side gunshot abdominal injury . the patient was transferred from a second level hospital to the national trauma centre 6 hours after the event . on admission his blood pressure was 120/80 mmhg , heart rate 90 beats per minute and respiratory rate 18 breaths /minutes . physical examination revealed a gunshot wound at the right side of the abdomen , and no exit point . standing plain x - ray revealed the presence of a metallic foreign body at the level of the 12th thoracic vertebra . computed tomography revealed free air in the abdomen and an hematoma surrounding the inferior cava vein below renal vessels ( figure 2 ) . ct of the bullet in the right ventricle . whether the bullet was in the heart or not was a matter of discussion between surgeons and radiologists ( figure 3 ) . the patient was taken to the operating room due to the free air in the abdomen , without precise knowledge of the position of the bullet and diagnosis of inferior cava vein injury . median abdominal incision was carried out . in the abdomen we found a contained hematoma with laceration of the inferior cava vein below renal vessels . we performed lateral suture using prolen 5 - 0 of the inferior cava vein and resection of 15 cm of terminal ileum with primary end to end anastomosis . during abdominal exploration we found adhesions due to a previous operation the patient had undergone for another abdominal trauma . with the abdominal phase completion we noticed no point of injury of the diaphragm . after pericardiotomy and precise localisation of the bullet in the right ventricle , extraction by direct cardiotomy without cardiopulmonary bypass was completed ( figures 4,5 ) . after the operation an increase of st wave in v1 , v2 , and v3 was present , which became normal two days later . left lung athelectasis required bronco - scopic toilette . the patient left the hospital on the 12-th postoperative day with no ecg , echocardiography abnormalities . bullet embolism from injured blood vessels can happen in cases of low kinetic energy and appropriate calibre . adhesions in abdomen due to previous operation were the cause of contained hematoma around lacerated inferior cava vein . that was the reason of almost normal healthy condition of the patient on admission . on top of that our emergency department lackeds the necessary equipments for the cardiopulmonary bypass . of outmost importance is the precise diagnosis in cases where foreign body embolism in the heart from an injured vein , is suspected . in our case , partly due to the lack of the equipments for a more accurate bullet localisation , and partly due to the limited experience in interpreting chest computer tomography in such cases , we performed the above described surgical approach . if not e - xplored the expansion   or infection   of the retroperitoneal hematoma was a probable complication , as well as complications related to intracardiac foreign body presence , the most frequent being bacterial endocarditis . the patient had to be operated as soon as possible for the presence of free air in abdomen and the first signs of peritonitis .
gunshot injuries of the human body challenge surgical teams in the emergency department . since such injuries do not follow any rule , every patient should be considered a special case . our case , of bullet embolism from injured inferior cava vein to the right heart ventricle is a rare one . 
 such cases make us be more alert for diagnosis and treatment of this kind of injury . 
 well equipped hospitals and experienced medical teams are necessary for successful outcome .