Massive cement pulmonary embolism during percutaneous vertebroplasty

Abstract

A 71-year-old woman was admitted to hospital after a car crash and diagnosed with L1 vertebral body fracture. A percutaneous transpedicular lumbar fixation using polymethylmethacrylate (PMMA) cement was decided. During the procedure, a massive PMMA cement leakage into the paravertebral venous system was observed. Hypotension, acute respiratory distress and refractory hypoxaemia were rapidly manifested. A cement pulmonary embolism was suspected and an unenhanced CT performed. A large collection of PMMA fragments were distinguished in the right pulmonary artery (RPA) and lobar branches ( figure 1A). A huge PMMA piece was seen inside the RV (figure 1B) and identified on chest radiography (figure 1C). Because of the critical condition of the patient and the size of the cement pieces, surgical management was decided. During anaesthesia induction, hypotension and ventricular tachycardia appeared. Cardiopulmonary bypass was immediately established. Through the right atriotomy, the RV was explored without findings. Afterwards, an RPA arteriotomy revealed elongated PMMA fragments in the right pulmonary branches ( figure 1D). A main pulmonary trunk arteriotomy showed a huge PMMA piece entrapped in the main pulmonary bifurcation ( figure 1E). A large collection of cement fragments were successfully removed ( figure 1F). The larger piece resembled the big one detected inside the RV on CT and chest radiography, probably embolised during induction of anaesthesia and responsible for the final acute hemodynamic instability. Postoperatively, the patient recovered uneventfully.PMMA cement pulmonary artery embolism is a rare complication after percutaneous vertebroplasty. Frequently underreported, clinical manifestations are variable, from asymptomatic to respiratory distress or death. Treatment is controversial. The current trend consists of conservative management. Pulmonary embolectomy is exceptional and usually associated with high mortality. Figure 1 (A) Unenhanced CT shows several hyperdense intraluminal opacities into the distal right pulmonary artery (RPA) and lobar branches (arrow). (B) CT scan reveals a hyperdense material inside the RV consistent with cement embolism. (C) Chest radiograph confirming presence of a big cement piece inside the RV. (D) Extraction of filamentous fragments of polymethylmethacrylate (PMMA) from the RPA. (E) Removal of the big PMMA cement piece through the main pulmonary trunk arteriotomy, consistent with the big piece observed preoperatively inside the RV on CT scan and chest radiograph. (F) All PMMA fragments removed during surgery.

A Review of PMMA Bone Cement and Intra‐Cardiac Embolism

“…Intra-cardiac embolism (ICE) secondary to PMMA leakage could be an incidental finding or it may appear during the procedure, immediately following the procedure, during hospital recovery, or even manifest as a long term complication (ranging from days to years) (Table 2, [30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51]). The clinical significance of cement emboli as an incidental finding on chest radiographs may not be ignored due to their known long-term sequelae.…”

“…However, no direct indicators have been identified up to now that can predict cement leakage to prove superiority of the viscoplastic cement. Further long-term outcome studies comparing cemented to cementless arthroplasty are still needed [24,36]. The possibility of cementless vertebroplasty remains unknown.…”

A Review of PMMA Bone Cement and Intra-Cardiac Embolism

“…However, no direct indicators have been identified till date to predict cement leakage to prove superiority of viscoplastic cement. Further long-term outcome studies comparing cemented to cementless arthroplasty are still needed [24,36]. The possibility of Cementless vertebroplasty remains unknown.…”

Abnormal Chest X-ray and Computed Tomography Post–Lumbar Fusion

“…Interestingly, studies that identified the emboli as being nonsignificant were measured at 2-3 cm in size as opposed to this case, where the embolism was much larger. 2 The differential diagnosis in a patient who has chest discomfort, dyspnea, or fatigue postoperatively should be considered for pulmonary embolus, but even more so if methylmethacrylate was used in a recent procedure.…”

“…Frequently underreported, clinical manifestations are variable, ranging from no symptoms to acute respiratory distress or death. 2 The frequency, outcome, and image findings of methylmethacrylate pulmonary embolism are poorly understood (Figure 3). 3 Key clues to cement embolism on imaging are:…”