Bullet emboli

Case contributed by Jayanth Keshavamurthy
Diagnosis certain


ICU chest radiograph.

Patient Data

Age: 70 years
Gender: Male

Endotracheal tube is demonstrated 5 cm above the carina. A left internal jugular central line is demonstrated with the tip at the SVC. A right-sided PICC line is demonstrated with the tip at the cavoatrial junction. Heart is normal size. Thoracic aorta is partially calcified.

Lungs are clear with normal vascularity and inflation.

A small metallic birdshot like radiopaque foreign body projects at the right atrium-IVC junction.

Scout radiograph from the CT shows multiple birdshot pellets.


Right greater than left pleural effusion.

Right lower lobe alveolar opacity.

Artefact from the bullet in the IVC-RA junction trapped in the Eustachian valve.

Case Discussion

Actually, on the CT the resident thought the linear artefact as a retained pacemaker wire.

A metallic density is identified within the inferior aspect of the right atrium, which is favored to represent a small segment of retained pacer lead. Results have been communicated by radiology to the primary team regarding this small fragment of a retained pacer lead.

It is important not forget to review the scout.

CT obtained in a beating heart and see how the computer generates a line on sagittal and coronal images and will fool you.

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