Clinical Orthopaedics and Related Research®
Clin Orthop Relat Res DOI 10.1007/s11999-014-3506-0
A Publication of The Association of Bone and Joint Surgeons®
CASE REPORT
Pulmonary Cement Embolization After Vertebroplasty Requiring Pulmonary Wedge Resection Marcus A. Rothermich MD, Jacob M. Buchowski MD, MS, David B. Bumpass MD, G. Alexander Patterson MD
Received: 8 November 2013 / Accepted: 4 February 2014 Ó The Association of Bone and Joint Surgeons1 2014
Abstract Background Pulmonary cement embolization after vertebroplasty is a well-known complication but typically presents with minimal respiratory symptoms. Although this rare complication has been reported, the current literature does not address the need for awareness of symptoms of potentially devastating respiratory compromise. Case Description We present the case of a 29-year-old man who underwent T11 vertebroplasty and subsequently had chest pain develop several days later. His right lower lung lobe had infarcted owing to massive cement embolization to his pulmonary arterial circulation. Open pulmonary wedge resection and embolectomy were performed. The patient recovered from the embolectomy but had chronic, persistent respiratory symptoms after surgery.
J. M. Buchowski is a consultant for CoreLink, Inc., Globus Medical, Inc., K2M, Inc., Medtronic, Inc.; and Stryker, Inc.; has teaching arrangements with Globus Medical, Inc., K2M, Inc., and Stryker, Inc.; receives royalties from Globus Medical, Inc. and Wolters Kluwer Health—Lippincott Williams & Wilkins; and has received institutional grant funding from K2M, Inc. and OREF. Each other author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. M. A. Rothermich, J. M. Buchowski (&), D. B. Bumpass, G. A. Patterson Department of Orthopaedic Surgery, Washington University in St Louis, 660 S Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA e-mail: [email protected]
Literature Review Operative management of vertebral compression fractures has included percutaneous vertebroplasty for the past 25 years. The reported incidence of pulmonary cement emboli after vertebroplasty ranges from 2.1% to 26% with much of this variation resulting from which radiographic technique is used to detect embolization. Symptoms of pulmonary cement embolism can occur during the procedure, but more commonly begin days to weeks, even months, after vertebroplasty. At least six deaths from cement embolization after vertebroplasty have been reported. Most cases of pulmonary cement emboli with cardiovascular and pulmonary complications are treated nonoperatively with anticoagulation. Endovascular removal of large cement emboli from the pulmonary arteries is not without risk and sometimes requires open surgery for complete removal of cement pieces. Clinical Relevance Pulmonary cement embolism is a potentially serious complication of vertebroplasty. If a patient has chest pain or respiratory difficulty after the procedure, chest radiography and possibly advanced chest imaging studies should be performed immediately.
Introduction Operative management of vertebral compression fractures has included percutaneous vertebroplasty for the past 25 years. Although pulmonary cement emboli after percutaneous vertebroplasty occur in as many as 26% of patients [53], most of these patients are asymptomatic and are treated nonoperatively with anticoagulation [19, 24, 31, 37, 39, 50, 57], although rarely, open cardiovascular surgery is needed to remove large cardiopulmonary emboli [13]. Symptoms of pulmonary cement emboli can occur during the procedure, but
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more commonly symptoms occur later, sometimes weeks or months after the procedure [1, 9, 13, 22, 33, 35, 48]. Endovascular removal of large cement emboli from the pulmonary arteries is a potentially attractive option, but even that entails some risk, and sometimes open surgery is still needed to achieve complete removal of the cement pieces [2, 7]. We present the findings from one patient who underwent pulmonary resection resulting from necrosis from cement embolization; to our knowledge, this is the only case report of this sort. In addition, we describe open embolectomy of cement emboli from the pulmonary circulation, which, to our knowledge, has been presented in only three previous cases [14, 33, 51].
Case Report A 29-year-old man presented to an outside hospital for vertebroplasty of the T11 vertebral body using polymethylmethacrylate (PMMA) cement. The stated indication for vertebroplasty was for treatment of chronic back pain after a T11 vertebral body fracture sustained in a motorcycle accident 3 years before. The patient had persistent low back pain owing to the T11 vertebral body fracture, and conservative treatment of oral pain medications had failed. At the time of the procedure, the patient was a healthy but inactive 29-yearold man with no respiratory symptoms. The patient tolerated the procedure well and was discharged home in stable condition. On Day 8 after the procedure, he began experiencing progressive right-sided chest pain and was urgently brought to another outside hospital for further evaluation and
Fig. 1 The chest CT scan performed on Day 8 after the T11 vertebroplasty shows cement tracking from the vertebral body to the thoracic segmental vein.
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treatment. He had hypoxia (initial pO2 of 59) and hypercarbia (initial CO2 of 31), and a chest CT showed cement tracking to the thoracic segmental vein (Fig. 1) and diffuse bilateral pulmonary cement emboli with a wedge-shaped opacity in the lateral aspect of the right lower lobe consistent with infarction (Fig. 2). Eleven days after the vertebroplasty, he underwent a thoracotomy and wedge resection of a portion of the right lower lobe, which had infarcted as a result of the cement embolism. Chest CT with intravenous contrast was repeated at our tertiary academic hospital for further evaluation of the bilateral pulmonary cement emboli. The CT scans again showed PMMA in multiple pulmonary arterial branches bilaterally (Fig. 3). A three-dimensional reconstruction of the CT clearly shows the multiple branches involved (Fig. 4). The patient underwent an embolectomy through a median sternotomy using cardiopulmonary bypass. On the right side, a PMMA embolus straddling the bifurcation of the first upper lobar truncal branch and the descending pulmonary artery was extracted. On the left side, several large PMMA emboli were removed from the upper lobe arterial branches. During the first 3 postoperative months, he had several episodes of persistent and severe dyspnea that were evaluated at his local regional medical center. He continued to have a chronic and debilitating pulmonary deficit because of his complication and the subsequent procedure, and is
Fig. 2 Another CT scan obtained on Day 8 after the T11 vertebroplasty shows a diffuse bilateral pulmonary cement embolism with a wedge-shaped opacity in the lateral aspect of the right lower lobe consistent with infarction.
Pulmonary Cement Embolization
Fig. 3 A chest CT scan performed after the thoracotomy and wedge resection shows multiple opaque areas of PMMA in the bilateral pulmonary arterial branches.
Fig. 4 A three-dimensional reconstruction of a chest CT scan performed after the thoracotomy and wedge resection shows multiple areas of PMMA in the bilateral pulmonary arterial branches.
being treated at his local regional medical center for the ongoing effects of the pulmonary cement embolism.
Discussion We present the case of a 29-year-old man who underwent a T11 vertebroplasty and subsequently had a massive cement
embolization to his pulmonary arterial circulation that required open pulmonary wedge resection and embolectomy. Operative treatment of vertebral compression fractures has included percutaneous vertebroplasty for the past 25 years. This procedure, which has gained popularity since its original description by Galibert et al. [20] in 1987, is used routinely to reduce pain and prevent additional vertebral body collapse, typically in elderly patients with osteoporosis. Vertebroplasty is not without controversy, however. Studies by Buchbinder et al. [8] and Kallmes et al. [25] showed no improvements in pain or pain-related disability over the control groups. The reported incidences of pulmonary cement embolism after vertebroplasty range from 2.1% to 26% with much of this variation resulting from which radiographic technique is used to detect the embolization [11, 15, 28, 53, 54]. The risk of pulmonary cement embolism exists with vertebroplasty and kyphoplasty, and comparative studies to date have not shown a significant difference in risk between the two techniques [11, 16, 23]. Pulmonary cement embolism occurs through the valveless vertebral venous plexus that provides connections to the primary thoracic venous system [21, 38]. Extruded PMMA rapidly polymerizes, but in rare cases travels from the paravertebral veins to the inferior vena cava, renal veins, the right heart, the brain (paradoxically as a result of a patent foramen ovale), and the pulmonary arterial system [4–6, 9–13, 17, 26, 30, 36–39, 41, 42, 44–47, 50, 57]. Arterial embolization to the aorta and anterior spinal artery also has been described [3, 52, 55]. Abdul-Jalil et al. [1] postulated that PMMA causes a prothrombotic effect and endothelial injury that can result in additional thrombosis of pulmonary vessels. The severity of our patient’s complication required an aggressive surgical procedure to remove the emboli, and typically such an invasive procedure is not required. Some patients who experience pulmonary cement embolism are asymptomatic [34, 35, 43]. A pulmonary cement embolism can present with arrhythmia, hypotension, hypoxia, dry cough, progressive dyspnea, or chest pain [19, 22, 24, 31, 57]. Acute respiratory distress syndrome also can be caused by a pulmonary cement embolism [56]. Symptoms of pulmonary cement embolism can occur during the procedure, but more commonly begin days to weeks, even months, after the vertebroplasty [1, 9, 13, 22, 33, 35, 48]. At least six deaths from cement embolization after vertebroplasty have been reported [10, 17, 36, 38, 49, 56]. Our patient’s right-sided chest pain was the initial presenting symptom on postoperative Day 8 from the original percutaneous thoracic vertebroplasty. Treatment for pulmonary cement embolism is typically close respiratory monitoring, but there have been nine reports [9, 14, 18, 27, 32, 33, 45, 48, 51] of surgery requiring
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cardiopulmonary bypass to remove cement emboli and only three [27, 32, 48] in which pulmonary arteriotomy was necessary. Several reports of cardiac perforation and tamponade caused by pulmonary cement embolism have been published; these patients required open surgical removal and cardiopulmonary bypass [9, 27, 32, 45, 48]. Dash and Brinster [14] reported the case of a patient who had migration of cement emboli from the right atrium and ventricle into the pulmonary circulation. Surgical exploration revealed no visible emboli in the pulmonary arteries, but a 5cm piece of cement was removed from the cavoatrial junction. Lim et al. [33] reported a case in which a patient presented more than 2 months after vertebroplasty with several cement emboli in the lungs and multiple cement pieces that had pierced the right ventricular wall. The patient underwent open surgery on cardiopulmonary bypass for removal of the cement pieces from the heart wall; the main pulmonary artery also was opened and a small string-like cement embolus was removed. Tozzi et al. [51] discussed the case of a patient who had immediate respiratory distress after vertebroplasty resulting from large cement emboli in the right and left pulmonary arteries. Open embolectomy with cardiopulmonary bypass yielded 9 g of cement from the pulmonary circulation. Francois et al. [18] described a cement embolus removed from the main pulmonary artery via a combination of endovascular and open-heart techniques. The cement was first grasped with an endovascular snare and brought through the right heart to the cavoatrial junction. Because the cement piece was too large to be brought out through the inferior vena cava, an open right atriotomy was performed on cardiopulmonary bypass to remove the captured cement. Most cases of pulmonary cement embolism with cardiovascular and pulmonary complications are treated nonoperatively with anticoagulation [19, 24, 31, 37, 39, 50, 57]. Krueger et al. [29] proposed a management algorithm that includes observation for peripheral asymptomatic embolisms, anticoagulation therapy for patients with either a symptomatic peripheral embolism or an asymptomatic central embolism, and surgical intervention for symptomatic central embolisms only. Others have advocated removal of cement emboli using endovascular techniques to prevent migration from the inferior vena cava to the lungs or to remove symptomatic pulmonary emboli [2, 4, 5, 7]. Endovascular removal of large cement emboli from the pulmonary arteries is not without risk and sometimes requires open surgery for complete removal of cement pieces [2, 7]. Suggestions to minimize the risk of pulmonary cement embolisms include prone positioning, maintaining elevated intrathoracic pressures, and the use of blush venography before cement injection [21, 40]. A standard chest radiograph after the procedure also is suggested [1].
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Good technique is critical in percutaneous vertebroplasty, which includes injecting an appropriate amount of cement. An awareness of the potential seriousness of cement embolization should considered by physicians performing vertebroplasty and caution taken to carefully observe for cement extravasation. The patient should be carefully monitored postoperatively for respiratory symptoms, and instructed to immediately notify the performing physician if such symptoms arise. Moreover, the risk of this complication should be clearly stated to patients before the intervention.
References 1. Abdul-Jalil Y, Bartels J, Alberti O, Becker R. Delayed presentation of pulmonary polymethylmethacrylate emboli after percutaneous vertebroplasty. Spine (Phila Pa 1976). 2007;32:E589–593. 2. Agko M, Nazzal M, Jamil T, Castillo-Sang M, Clark P, Kasper G. Prevention of cardiopulmonary embolization of polymethylmethacrylate cement fragment after kyphoplasty with insertion of inferior vena cava filter. J Vasc Surg. 2010;51:210–213. 3. Amoretti N, Hovorka I, Marcy PY, Grimaud A, Brunner P, Bruneton JN. Aortic embolism of cement: a rare complication of lumbar percutaneous vertebroplasty. Skeletal Radiol. 2007;36:685–687. 4. Athreya S, Mathias N, Rogers P, Edwards R. Retrieval of cement embolus from inferior vena cava after percutaneous vertebroplasty. Cardiovasc Intervent Radiol. 2009;32:817–819. 5. Baumann A, Tauss J, Baumann G, Tomka M, Hessinger M, Tiesenhausen K. Cement embolization into the vena cava and pulmonal arteries after vertebroplasty: interdisciplinary management. Eur J Vasc Endovasc Surg. 2006;31:558–561. 6. Bonardel G, Pouit B, Gontier E, Dutertre G, Mantzarides M, Goasguen O, Foehrenbach H. Pulmonary cement embolism after percutaneous vertebroplasty: a rare and nonthrombotic cause of pulmonary embolism. Clin Nucl Med. 2007;32:603–606. 7. Bose R, Choi JW. Successful percutaneous retrieval of methyl methacrylate orthopedic cement embolism from the pulmonary artery. Catheter Cardiovasc Interv. 2010;76:198–201. 8. Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt C, Graves S, Staples MP, Murphy B. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361:557–568. 9. Caynak B, Onan B, Sagbas E, Duran C, Akpinar B. Cardiac tamponade and pulmonary embolism as a complication of percutaneous vertebroplasty. Ann Thorac Surg. 2009;87:299–301. 10. Chen HL, Wong CS, Ho ST, Chang FL, Hsu CH, Wu CT. A lethal pulmonary embolism during percutaneous vertebroplasty. Anesth Analg. 2002;95:1060–1062. 11. Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE. Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol. 2004;183:1097–1102. 12. Chung SE, Lee SH, Kim TH, Yoo KH, Jo BJ. Renal cement embolism during percutaneous vertebroplasty. Eur Spine J. 2006;15(suppl 5):590–594. 13. Cohen J, Lane T. Right intra-atrial and ventricular polymethylmethacrylate embolus after balloon kyphoplasty. Am J Med. 2010;123:e5–6. 14. Dash A, Brinster DR. Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty. Ann Thorac Surg. 2011;91:276–8.
Pulmonary Cement Embolization 15. Duran C, Sirvanci M, Aydogan M, Ozturk E, Ozturk C, Akman C. Pulmonary cement embolism: a complication of percutaneous vertebroplasty. Acta Radiol. 2007;48:854–9. 16. Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Comparison of vertebroplasty and balloon kyphoplasty for treatment of vertebral compression fractures: a meta-analysis of the literature. Spine J. 2008;8:488–497. 17. Franco E, Frea S, Solaro C, Conti V, Pinneri F. Fatal pulmonary embolism: when the cause is not a thrombus. Spine (Phila Pa 1976). 2012;37:E411–413. 18. Francois K, Taeymans Y, Poffyn B, Van Nooten G. Successful management of a large pulmonary cement embolus after percutaneous vertebroplasty: a case report. Spine (Phila Pa 1976). 2003;28:E424–425. 19. Freitag M, Gottschalk A, Schuster M, Wenk W, Wiesner L, Standl TG. Pulmonary embolism caused by polymethylmethacrylate during percutaneous vertebroplasty in orthopaedic surgery. Acta Anaesthesiol Scand. 2006;50:248–2551. 20. Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie. 1987;33:166–168. 21. Groen RJ, du Toit DF, Phillips FM, Hoogland PV, Kuizenga K, Coppes MH, Muller CJ, Grobbelaar M, Mattyssen J. Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: a reappraisal of the vertebral venous system. Spine (Phila Pa 1976). 2004;29:1465–1471. 22. Habib N, Maniatis T, Ahmed S, Kilkenny T, Alkaied H, Elsayegh D, Chalhoub M, Harris K. Cement pulmonary embolism after percutaneous vertebroplasty and kyphoplasty: An overview. Heart Lung. 2012;41:509–511. 23. Hulme PA, Krebs J, Ferguson SJ, Berlemann U. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine (Phila Pa 1976). 2006;31:1983–2001. 24. Jang JS, Lee SH, Jung SK. Pulmonary embolism of polymethylmethacrylate after percutaneous vertebroplasty: a report of three cases. Spine (Phila Pa 1976). 2002;27:E416–418. 25. Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingsworth W, Ghdoke B, Annesley-Williams DJ, Ralston SH, Jarvik JG. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361:569–579. 26. Kao FC, Tu YK, Lai PL, Yu SW, Yen CY, Chou MC. Inferior vena cava syndrome following percutaneous vertebroplasty with polymethylmethacrylate. Spine (Phila Pa 1976). 2008;33:E329– 333. 27. Kim SY, Seo JB, Do KH, Lee JS, Song KS, Lim TH. Cardiac perforation caused by acrylic cement: a rare complication of percutaneous vertebroplasty. AJR Am J Roentgenol. 2005;185: 1245–1247. 28. Kim YJ, Lee JW, Park KW, Yeom JS, Jeong HS, Park JM, Kang HS. Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors. Radiology. 2009;251:250–259. 29. Krueger A, Bliemel C, Zettl R, Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J. 2009;18:1257–1265. 30. Lee JS, Jeong YS, Ahn SG. Intracardiac bone cement embolism. Heart. 2010;96:387. 31. Liliang PC, Lu K, Liang CL, Tsai YD, Hsieh CH, Chen HJ. Dyspnoea and chest pain associated with pulmonary polymethylmethacrylate embolism after percutaneous vertebroplasty. Injury. 2007;38:245–248. 32. Lim KJ, Yoon SZ, Jeon YS, Bahk JH, Kim CS, Lee JH, Ha JW. An intraatrial thrombus and pulmonary thromboembolism as a
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late complication of percutaneous vertebroplasty. Anesth Analg. 2007;104:924–926. Lim SH, Kim H, Kim HK, Baek MJ. Multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty. Eur J Cardiothorac Surg. 2008;33: 510–512. Luetmer MT, Bartholmai BJ, Rad AE, Kallmes DF. Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty. AJNR Am J Neuroradiol. 2011;32:654–657. MacTaggart JN, Pipinos, II, Johanning JM, Lynch TG. Acrylic cement pulmonary embolus masquerading as an embolized central venous catheter fragment. J Vasc Surg. 2006;43:180–183. Marden FA, Putman CM. Cement-embolic stroke associated with vertebroplasty. AJNR Am J Neuroradiol. 2008;29:1986–1988. Moll S, Kuzma C. Images in vascular medicine: cement pulmonary embolism. Vasc Med. 2010;15:339–340. Monticelli F, Meyer HJ, Tutsch-Bauer E. Fatal pulmonary cement embolism following percutaneous vertebroplasty (PVP). Forensic Sci Int. 2005;149:35–38. Padovani B, Kasriel O, Brunner P, Peretti-Viton P. Pulmonary embolism caused by acrylic cement: a rare complication of percutaneous vertebroplasty. AJNR Am J Neuroradiol. 1999;20:375–377. Peh WC, Gilula LA. Additional value of a modified method of intraosseous venography during percutaneous vertebroplasty. AJNR Am J Neuroradiol. 2003;180:87–91. Quesada N, Mutlu GM. Images in cardiovascular medicine: pulmonary embolization of acrylic cement during vertebroplasty. Circulation. 2006;113:e295–296. Radcliff KE, Reitman CA, Delasotta LA, Hong J, Dilorio T, Zaslavsky J, Vaccaro AR, Hipp JA. Pulmonary cement embolization after kyphoplasty: a case report and review of the literature. Spine J. 2010;10:e1–5. Ren H, Shen Y, Zhang YZ, Ding WY, Xu JX, Yang DL, Cao JM. Correlative factor analysis on the complications resulting from cement leakage after percutaneous kyphoplasty in the treatment of osteoporotic vertebral compression fracture. J Spinal Disord Tech. 2010;23:e9–15. Schneider L, Plit M. Pulmonary embolization of acrylic cement during percutaneous vertebroplasty. Intern Med J. 2007;37:423–425. Schoenes B, Bremerich DH, Risteski PS, Thalhammer A, Meininger D. Cardiac perforation after vertebroplasty. Anaesthesist. 2008;57:147–150. Scroop R, Eskridge J, Britz GW. Paradoxical cerebral arterial embolization of cement during intraoperative vertebroplasty: case report. AJNR Am J Neuroradiol. 2002;23:868–870. Seo JS, Kim YJ, Choi BW, Kim TH, Choe KO. MDCT of pulmonary embolism after percutaneous vertebroplasty. AJR Am J Roentgenol. 2005;184:1364–1365. Son KH, Chung JH, Sun K, Son HS. Cardiac perforation and tricuspid regurgitation as a complication of percutaneous vertebroplasty. Eur J Cardiothorac Surg. 2008;33:508–509. Stricker K, Orler R, Yen K, Takala J, Luginbuhl M. Severe hypercapnia due to pulmonary embolism of polymethylmethacrylate during vertebroplasty. Anesth Analg. 2004;98:1184–1186. Tourtier JP, Cottez S. Images in clinical medicine: pulmonary cement embolism after vertebroplasty. N Engl J Med. 2012;366: 258. Tozzi P, Abdelmoumene Y, Corno AF, Gersbach PA, Hoogewoud HM, von Segesser LK. Management of pulmonary embolism during acrylic vertebroplasty. Ann Thorac Surg. 2002;74:1706–1708. Tsai YD, Liliang PC, Chen HJ, Lu K, Liang CL, Wang KW. Anterior spinal artery syndrome following vertebroplasty: a case report. Spine (Phila Pa 1976). 2010;35:E134–136.
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Rothermich et al. 53. Venmans A, Klazen CA, Lohle PN, van Rooij WJ, Verhaar HJ, de Vries J, Mali WP. Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II. AJNR Am J Neuroradiol. 2010;31:1451–1453. 54. Venmans A, Lohle PN, van Rooij WJ, Verhaar HJ, Mali WP. Frequency and outcome of pulmonary polymethylmethacrylate embolism during percutaneous vertebroplasty. AJNR Am J Neuroradiol. 2008;29:1983–1985. 55. Yazbeck PG, Al Rouhban RB, Slaba SG, Kreichati GE, Kharrat KE. Anterior spinal artery syndrome after percutaneous vertebroplasty. Spine J. 2011;11:e5–8.
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Clin Orthop Relat Res DOI 10.1007/s11999-014-3506-0
A Publication of The Association of Bone and Joint Surgeons®
CASE REPORT
Pulmonary Cement Embolization After Vertebroplasty Requiring Pulmonary Wedge Resection Marcus A. Rothermich MD, Jacob M. Buchowski MD, MS, David B. Bumpass MD, G. Alexander Patterson MD
Received: 8 November 2013 / Accepted: 4 February 2014 Ó The Association of Bone and Joint Surgeons1 2014
Abstract Background Pulmonary cement embolization after vertebroplasty is a well-known complication but typically presents with minimal respiratory symptoms. Although this rare complication has been reported, the current literature does not address the need for awareness of symptoms of potentially devastating respiratory compromise. Case Description We present the case of a 29-year-old man who underwent T11 vertebroplasty and subsequently had chest pain develop several days later. His right lower lung lobe had infarcted owing to massive cement embolization to his pulmonary arterial circulation. Open pulmonary wedge resection and embolectomy were performed. The patient recovered from the embolectomy but had chronic, persistent respiratory symptoms after surgery.
J. M. Buchowski is a consultant for CoreLink, Inc., Globus Medical, Inc., K2M, Inc., Medtronic, Inc.; and Stryker, Inc.; has teaching arrangements with Globus Medical, Inc., K2M, Inc., and Stryker, Inc.; receives royalties from Globus Medical, Inc. and Wolters Kluwer Health—Lippincott Williams & Wilkins; and has received institutional grant funding from K2M, Inc. and OREF. Each other author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. M. A. Rothermich, J. M. Buchowski (&), D. B. Bumpass, G. A. Patterson Department of Orthopaedic Surgery, Washington University in St Louis, 660 S Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA e-mail: [email protected]
Literature Review Operative management of vertebral compression fractures has included percutaneous vertebroplasty for the past 25 years. The reported incidence of pulmonary cement emboli after vertebroplasty ranges from 2.1% to 26% with much of this variation resulting from which radiographic technique is used to detect embolization. Symptoms of pulmonary cement embolism can occur during the procedure, but more commonly begin days to weeks, even months, after vertebroplasty. At least six deaths from cement embolization after vertebroplasty have been reported. Most cases of pulmonary cement emboli with cardiovascular and pulmonary complications are treated nonoperatively with anticoagulation. Endovascular removal of large cement emboli from the pulmonary arteries is not without risk and sometimes requires open surgery for complete removal of cement pieces. Clinical Relevance Pulmonary cement embolism is a potentially serious complication of vertebroplasty. If a patient has chest pain or respiratory difficulty after the procedure, chest radiography and possibly advanced chest imaging studies should be performed immediately.
Introduction Operative management of vertebral compression fractures has included percutaneous vertebroplasty for the past 25 years. Although pulmonary cement emboli after percutaneous vertebroplasty occur in as many as 26% of patients [53], most of these patients are asymptomatic and are treated nonoperatively with anticoagulation [19, 24, 31, 37, 39, 50, 57], although rarely, open cardiovascular surgery is needed to remove large cardiopulmonary emboli [13]. Symptoms of pulmonary cement emboli can occur during the procedure, but
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more commonly symptoms occur later, sometimes weeks or months after the procedure [1, 9, 13, 22, 33, 35, 48]. Endovascular removal of large cement emboli from the pulmonary arteries is a potentially attractive option, but even that entails some risk, and sometimes open surgery is still needed to achieve complete removal of the cement pieces [2, 7]. We present the findings from one patient who underwent pulmonary resection resulting from necrosis from cement embolization; to our knowledge, this is the only case report of this sort. In addition, we describe open embolectomy of cement emboli from the pulmonary circulation, which, to our knowledge, has been presented in only three previous cases [14, 33, 51].
Case Report A 29-year-old man presented to an outside hospital for vertebroplasty of the T11 vertebral body using polymethylmethacrylate (PMMA) cement. The stated indication for vertebroplasty was for treatment of chronic back pain after a T11 vertebral body fracture sustained in a motorcycle accident 3 years before. The patient had persistent low back pain owing to the T11 vertebral body fracture, and conservative treatment of oral pain medications had failed. At the time of the procedure, the patient was a healthy but inactive 29-yearold man with no respiratory symptoms. The patient tolerated the procedure well and was discharged home in stable condition. On Day 8 after the procedure, he began experiencing progressive right-sided chest pain and was urgently brought to another outside hospital for further evaluation and
Fig. 1 The chest CT scan performed on Day 8 after the T11 vertebroplasty shows cement tracking from the vertebral body to the thoracic segmental vein.
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treatment. He had hypoxia (initial pO2 of 59) and hypercarbia (initial CO2 of 31), and a chest CT showed cement tracking to the thoracic segmental vein (Fig. 1) and diffuse bilateral pulmonary cement emboli with a wedge-shaped opacity in the lateral aspect of the right lower lobe consistent with infarction (Fig. 2). Eleven days after the vertebroplasty, he underwent a thoracotomy and wedge resection of a portion of the right lower lobe, which had infarcted as a result of the cement embolism. Chest CT with intravenous contrast was repeated at our tertiary academic hospital for further evaluation of the bilateral pulmonary cement emboli. The CT scans again showed PMMA in multiple pulmonary arterial branches bilaterally (Fig. 3). A three-dimensional reconstruction of the CT clearly shows the multiple branches involved (Fig. 4). The patient underwent an embolectomy through a median sternotomy using cardiopulmonary bypass. On the right side, a PMMA embolus straddling the bifurcation of the first upper lobar truncal branch and the descending pulmonary artery was extracted. On the left side, several large PMMA emboli were removed from the upper lobe arterial branches. During the first 3 postoperative months, he had several episodes of persistent and severe dyspnea that were evaluated at his local regional medical center. He continued to have a chronic and debilitating pulmonary deficit because of his complication and the subsequent procedure, and is
Fig. 2 Another CT scan obtained on Day 8 after the T11 vertebroplasty shows a diffuse bilateral pulmonary cement embolism with a wedge-shaped opacity in the lateral aspect of the right lower lobe consistent with infarction.
Pulmonary Cement Embolization
Fig. 3 A chest CT scan performed after the thoracotomy and wedge resection shows multiple opaque areas of PMMA in the bilateral pulmonary arterial branches.
Fig. 4 A three-dimensional reconstruction of a chest CT scan performed after the thoracotomy and wedge resection shows multiple areas of PMMA in the bilateral pulmonary arterial branches.
being treated at his local regional medical center for the ongoing effects of the pulmonary cement embolism.
Discussion We present the case of a 29-year-old man who underwent a T11 vertebroplasty and subsequently had a massive cement
embolization to his pulmonary arterial circulation that required open pulmonary wedge resection and embolectomy. Operative treatment of vertebral compression fractures has included percutaneous vertebroplasty for the past 25 years. This procedure, which has gained popularity since its original description by Galibert et al. [20] in 1987, is used routinely to reduce pain and prevent additional vertebral body collapse, typically in elderly patients with osteoporosis. Vertebroplasty is not without controversy, however. Studies by Buchbinder et al. [8] and Kallmes et al. [25] showed no improvements in pain or pain-related disability over the control groups. The reported incidences of pulmonary cement embolism after vertebroplasty range from 2.1% to 26% with much of this variation resulting from which radiographic technique is used to detect the embolization [11, 15, 28, 53, 54]. The risk of pulmonary cement embolism exists with vertebroplasty and kyphoplasty, and comparative studies to date have not shown a significant difference in risk between the two techniques [11, 16, 23]. Pulmonary cement embolism occurs through the valveless vertebral venous plexus that provides connections to the primary thoracic venous system [21, 38]. Extruded PMMA rapidly polymerizes, but in rare cases travels from the paravertebral veins to the inferior vena cava, renal veins, the right heart, the brain (paradoxically as a result of a patent foramen ovale), and the pulmonary arterial system [4–6, 9–13, 17, 26, 30, 36–39, 41, 42, 44–47, 50, 57]. Arterial embolization to the aorta and anterior spinal artery also has been described [3, 52, 55]. Abdul-Jalil et al. [1] postulated that PMMA causes a prothrombotic effect and endothelial injury that can result in additional thrombosis of pulmonary vessels. The severity of our patient’s complication required an aggressive surgical procedure to remove the emboli, and typically such an invasive procedure is not required. Some patients who experience pulmonary cement embolism are asymptomatic [34, 35, 43]. A pulmonary cement embolism can present with arrhythmia, hypotension, hypoxia, dry cough, progressive dyspnea, or chest pain [19, 22, 24, 31, 57]. Acute respiratory distress syndrome also can be caused by a pulmonary cement embolism [56]. Symptoms of pulmonary cement embolism can occur during the procedure, but more commonly begin days to weeks, even months, after the vertebroplasty [1, 9, 13, 22, 33, 35, 48]. At least six deaths from cement embolization after vertebroplasty have been reported [10, 17, 36, 38, 49, 56]. Our patient’s right-sided chest pain was the initial presenting symptom on postoperative Day 8 from the original percutaneous thoracic vertebroplasty. Treatment for pulmonary cement embolism is typically close respiratory monitoring, but there have been nine reports [9, 14, 18, 27, 32, 33, 45, 48, 51] of surgery requiring
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cardiopulmonary bypass to remove cement emboli and only three [27, 32, 48] in which pulmonary arteriotomy was necessary. Several reports of cardiac perforation and tamponade caused by pulmonary cement embolism have been published; these patients required open surgical removal and cardiopulmonary bypass [9, 27, 32, 45, 48]. Dash and Brinster [14] reported the case of a patient who had migration of cement emboli from the right atrium and ventricle into the pulmonary circulation. Surgical exploration revealed no visible emboli in the pulmonary arteries, but a 5cm piece of cement was removed from the cavoatrial junction. Lim et al. [33] reported a case in which a patient presented more than 2 months after vertebroplasty with several cement emboli in the lungs and multiple cement pieces that had pierced the right ventricular wall. The patient underwent open surgery on cardiopulmonary bypass for removal of the cement pieces from the heart wall; the main pulmonary artery also was opened and a small string-like cement embolus was removed. Tozzi et al. [51] discussed the case of a patient who had immediate respiratory distress after vertebroplasty resulting from large cement emboli in the right and left pulmonary arteries. Open embolectomy with cardiopulmonary bypass yielded 9 g of cement from the pulmonary circulation. Francois et al. [18] described a cement embolus removed from the main pulmonary artery via a combination of endovascular and open-heart techniques. The cement was first grasped with an endovascular snare and brought through the right heart to the cavoatrial junction. Because the cement piece was too large to be brought out through the inferior vena cava, an open right atriotomy was performed on cardiopulmonary bypass to remove the captured cement. Most cases of pulmonary cement embolism with cardiovascular and pulmonary complications are treated nonoperatively with anticoagulation [19, 24, 31, 37, 39, 50, 57]. Krueger et al. [29] proposed a management algorithm that includes observation for peripheral asymptomatic embolisms, anticoagulation therapy for patients with either a symptomatic peripheral embolism or an asymptomatic central embolism, and surgical intervention for symptomatic central embolisms only. Others have advocated removal of cement emboli using endovascular techniques to prevent migration from the inferior vena cava to the lungs or to remove symptomatic pulmonary emboli [2, 4, 5, 7]. Endovascular removal of large cement emboli from the pulmonary arteries is not without risk and sometimes requires open surgery for complete removal of cement pieces [2, 7]. Suggestions to minimize the risk of pulmonary cement embolisms include prone positioning, maintaining elevated intrathoracic pressures, and the use of blush venography before cement injection [21, 40]. A standard chest radiograph after the procedure also is suggested [1].
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Good technique is critical in percutaneous vertebroplasty, which includes injecting an appropriate amount of cement. An awareness of the potential seriousness of cement embolization should considered by physicians performing vertebroplasty and caution taken to carefully observe for cement extravasation. The patient should be carefully monitored postoperatively for respiratory symptoms, and instructed to immediately notify the performing physician if such symptoms arise. Moreover, the risk of this complication should be clearly stated to patients before the intervention.
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