• Users Online: 2949
  • Print this page
  • Email this page

 Table of Contents    
Year : 2021  |  Volume : 65  |  Issue : 5  |  Page : 412-413  

Surgical-conundrum of a hiding ‘Bullet’: Echocardiographic artefact clues the concealed fact!

1 Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, India
2 Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, India
3 Division of Trauma Surgery and Critical Care, Department of Surgical Discipline, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India

Date of Submission15-Sep-2020
Date of Decision29-Oct-2020
Date of Acceptance28-Mar-2021
Date of Web Publication20-May-2021

Correspondence Address:
Neeti Makhija
Room No. 9, 7th Floor, Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_1236_20

Rights and Permissions

How to cite this article:
Makhija N, Sharma A, Magoon R, Kumar A. Surgical-conundrum of a hiding ‘Bullet’: Echocardiographic artefact clues the concealed fact!. Indian J Anaesth 2021;65:412-3

How to cite this URL:
Makhija N, Sharma A, Magoon R, Kumar A. Surgical-conundrum of a hiding ‘Bullet’: Echocardiographic artefact clues the concealed fact!. Indian J Anaesth [serial online] 2021 [cited 2021 Jun 22];65:412-3. Available from: https://www.ijaweb.org/text.asp?2021/65/5/412/316536


Following a gun-shot trauma, a middle-aged male was conservatively managed for the resultant grade II hepatic injury only to eventually present for the surgical bullet extraction in our cardiothoracic operative suite. With the admission computed tomography of thoraco-abdomen scan delineating the 'bullet' as a foreign body lodging just lateral to the aorta at the D11-D12 vertebral level [Figure 1]a and [Figure 1]b, the surgical team planned a thoraco-abdominal incisional approach.
Figure 1: Thoraco-abdominal non-contrast CT scan in axial (a) and sagittal view (b) demonstrating foreign body (bullet) shown with arrow lying posteriorly between descending thoracic aorta (DTA) and the vertebrae at T11-12 level. A: Descending thoracic aorta, B: Bullet, C: Vertebrae

Click here to view

However, despite extensive exploration after the peri-aortic haematoma evacuation, surgical colleagues failed to discover the 'bullet'. The reported proximity of the 'bullet' and the aorta motivated an intraoperative transoesophageal echocardiography (TEE) aortic examination performed with an X7-2t Philips ultrasound probe and machine (iE33 model; Philips, Bothell, WA, USA). Interestingly, we noticed an unusual echogenic-shadow extending behind the distal most thoracic-aorta to the front of the spinal-cord on TEE [Figure 2]a,[Figure 2]b,[Figure 2]c. It is noteworthy that the spinal-cord can be precariously difficult to profile on TEE (until most meticulously visualised employing an inter-vertebral disc as an imaging window).[1]
Figure 2: Two dimensional (2D) transoesophageal echocardiography (TEE) (a) and real time 3D TEE (b) showing descending thoracic aorta (DTA) in short-axis view at transgastric level depicting an acoustic shadowing (marked by an arrow) extending antero-posteriorly from the DTA to the spinal-cord (s) raising a suspicion of an echogenic material lodging behind the posteriorly thickened aortic surface. (c) Schematic diagram showing TEE probe in the oesophagus with its relationship to DTA, acoustic shadowing and spinal cord at mid-oesophageal and at subdiaphragmatic level antero-posteriorly

Click here to view

Nevertheless, the echogenic-shadow was enough to raise suspicion, particularly in combination with the echocardiographic evidence of a thickened posterior aortic wall. The context-appropriate inference was suggestive of an embedded echogenic material ('bullet' in this case) casting a distal acoustic-shadow on TEE imaging (akin to a mirage to light, the acoustic-shadow emanates as a result of sound waves encountering highly echo-dense structures like prosthetic valves, bones, etc.).[2],[3]

Subsequent to the communication of the aforementioned, the 'bullet' hiding in the fibrous tissue accumulation posterior to the aorta was surgically retrieved with utmost care. Albeit in hindsight, the thoughtful team reflected upon the remarkable case-related peculiarities such as the intimate antero-posterior aortic-vertebral column relationship at lower thoracic levels[4] while to an echocardiographer's delight: a usual menace of acoustic-shadowing artefact stood out as a boon in the index case with yet another novel application of the dynamic imaging modality of TEE[5] for the perioperative physicians.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Ueda K, Shields BE, Brennan TJ. Transesophageal echocardiography: A novel technique for guidance and placement of an epidural catheter in infants. Anesthesiology 2013;118:219-22.  Back to cited text no. 1
Kaya A, Caliskan E, Tatlisu MA, Hayiroglu MI, Tekessin AI, Cakilli Y, et al. A retained bullet in pericardial sac: Penetrating gunshot injury of the heart. Case Rep Cardiol 2016;2016:2427681.  Back to cited text no. 2
Bertrand PB, Levine RA, Isselbacher EM, Vandervoort PM. Fact or artifact in two-dimensional echocardiography: Avoiding misdiagnosis and missed diagnosis. J Am Soc Echocardiogr 2016;29:381-91.  Back to cited text no. 3
Iyer MH, Engoren M, Martin MW. Echo rounds: Transesophageal echocardiography: Identification and management of a misplaced pedicle screw in the descending thoracic aorta after posterior spinal fusion. Anesth Analg 2013;116:303-6.  Back to cited text no. 4
Koshy T, Kumar B, Sinha PK. Transesophageal echocardiography and anaesthesiologist. Indian J Anaesth 2007;51:324-33.  Back to cited text no. 5
  [Full text]  


  [Figure 1], [Figure 2]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Article Figures

 Article Access Statistics
    PDF Downloaded34    
    Comments [Add]    

Recommend this journal