Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature

Abstract

Balloon kyphoplasty and percutaneous vertebroplasty are relatively recent procedures in the treatment of painful vertebral fractures. There are, however, still some uncertainties about the incidence and treatment strategies of pulmonary cement embolisms (PCE). In order to work out a treatment strategy for the management of this complication, we performed a review of the literature. The results show that there is no clear diagnostic or treatment standard for PCE. The literature research revealed that the risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up; in cases of symptomatic or central embolisms, however, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy. In order to avoid any types of embolisms, both procedures should only be performed by experienced surgeons after critical determination of the indications.

Percutaneous Vertebroplasty and Pulmonary Cement Embolism: Results from VERTOS II

“…[1][2][3][4][5][6] Occasionally, cement that has leaked into the veins may migrate into the lungs causing PCE. Although most PCEs remain asymptomatic, serious and even fatal sequelae have occasionally been reported.…”

Pulmonary cement emboli after kyphoplasty

“…Symptomatic patients, on the other hand, may be managed with heparin followed by warfarin for at least 6 months, which is hypothesized to allow endothelialization of the thrombogenic cement material and prevent progressive pulmonary artery occlusion [5]. Overall, this case highlights an unusual form of pulmonary emboli and underscores the need to consider a broad differential diagnosis for chest pain and shortness of breath in the setting of recent operative interventions, including vertebroplasty and kyphoplasty.…”

“…Cement extrusion has been estimated to occur in 3-70 % of vertebroplasties and 8-33 % kyphoplasties, with radiographically evident pulmonary cement emboli produced in 4.6 % of cases [3,4]. While there are no standards of care for the treatment and management of pulmonary cement emboli, asymptomatic individuals may be effectively managed conservatively with close clinical monitoring [5].…”

Late onset of pulmonary cement embolism after a regular vertebroplasy. A clinical documentation

“…In cases of symptomatic or central embolisms, however, treatment includes initial heparinization and a following 6-month coumarin therapy should be proceeded. A continuous anticoagulation therapy after the initial 6 months of treatment does not seem to be indicated and due to the associated bleeding complications in the prevalent older population it is actually contraindicated [4]. Even after review of the literature, it is not possible to derive a clear treatment strategy for the treatment of pulmonary cement embolisms.…”

“…Besides surgical removal, treatment options include administration of heparin i.v. or s.c., observation of the clinical spontaneous progress or coumarin treatment for 3-6 months after the occurrence of the embolism [4].…”