Ballistic fragment embolism to superior mesenteric artery after the shrapnel injury to the chest: a case report of casualty from Russia-Ukraine war

BACKGROUND: The Russia-Ukraine war has produced widespread lethal ballistic trauma with unusual injury patterns, including rare cases of projectile migration and arterial embolism. Prompt differential management near frontlines is crucial to improve outcomes and reduce evacuation risk. The aim of the study was to present clinical features, diagnostic workup, and management of a combat patient with a penetrating chest wound, cardiac involvement, and subsequent migration of a ballistic fragment into the superior mesenteric artery (SMA), and to contextualize this case within existing literature on ballistic emboli. CASE PRESENTATION: A 41-year-old serviceman sustained a chest injury from FPV-drone munitions. Initial delayed evacuation and staged imaging (X-ray, FAST, whole-body CT) identified a ballistic channel from chest to abdomen and a metallic intraluminal fragment in the SMA. Clinical decision-making weighed endovascular versus open approaches amid tactical constraints and patient consent dynamics. Contrast-enhanced CT suggested transcardiac migration of the fragment into the SMA. With absent critical mesenteric ischemia and delayed consent, laparotomy on day 14 revealed an intraluminal metallic fragment that was removed via arteriotomy with primary repair. The patient recovered and was discharged after 21 days. CONCLUSIONS: The arterial ballistic emboli must be suspected in patients with isolated chest- or thoracoabdominal injuries. The whole-body contrast-enhanced CT scan is an important diagnostic tool for patients with gunshot injuries. In the absence of evidence of bowel necrosis, surgery can be postponed in patients with SMA emboli. An important role in visualization is played by contrast-enhanced MSCT. We recommend removing projectile fragments from the major blood vessels.