ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tozzi, P.
Right arrow Articles by von Segesser, L. K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tozzi, P.
Right arrow Articles by von Segesser, L. K.
Related Collections
Right arrow Lung - other

Ann Thorac Surg 2002;74:1706-1708
© 2002 The Society of Thoracic Surgeons

Case report

Management of pulmonary embolism during acrylic vertebroplasty

Piergiorgio Tozzi, MDa*, Yasmine Abdelmoumene, MDb, Antonio F. Corno, MDa, Philip A. Gersbach, MDa, Henri-Marcel Hoogewoudc, Ludwig K. von Segesser, MDa

a Department of Cardiovascular Surgery, Lausanne, Switzerland
b Radiology, Centre Hôpitalier Universitaire Vaudois—CHUV, Lausanne, Switzerland
c Department of Radiology, Hôpital Cantonale Fribourg, Fribourg, Switzerland

Accepted for publication June 20, 2002.

* Address reprint requests to Dr Tozzi, Service de Chirurgie Cardiovasculaire—BH10, Centre Hôpitalier Universitaire Vaudois—CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland
e-mail: tozzig{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
A 55-year-old man diagnosed with osteogenesis imperfecta had multiple pulmonary embolism from acrylic cement during vertebroplasty. The patient immediately developed respiratory distress, renal failure, and right cardiac failure. A computed tomographic scan showed the presence of cement in the right and left pulmonary arteries, and in both lungs. Cardiac and respiratory functions did not improve with medical treatment, therefore the patient underwent pulmonary artery embolectomy. Cement was easily removed from both pulmonary arteries. The patient quickly recovered from respiratory and cardiac failure. We believe pulmonary embolectomy is a reliable and effective procedure to treat this rare and dreadful complication of acrylic vertebroplasty.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Acrylic cement vertebroplasty is currently used to remodel a diseased vertebral body [1]. One of the drawbacks of this technique is the cement leakage into the perivertebral venous system. Most of these leaks are asymptomatic, and if clinical evidence of pulmonary embolism occurs, the patient is usually treated only with anticoagulants [2, 3]. We report a case of symptomatic pulmonary embolism, caused by cement leakage during vertebroplasty, in which anticoagulation therapy revealed all its limits and the patient required a more aggressive treatment.

A 55-year-old man diagnosed with osteogenesis imperfecta was hospitalized for spontaneous fracture of the 11th thoracic vertebra (T11) and treated with bipedicular vertebroplasty under general anesthesia. Polymethyl methacrylate (Palacos LV-40 [Schering-Plough Corp, Kenilworth, NJ]) mixed with iodamide (Uromiro [Bracco, Milano, Italy]) was injected in the vertebral body of T11, T12, and all lumbar vertebras (L1 to L5) under fluoroscopic control. At the end of the procedure, the patient had severe hypoxemia (SpO2 85%, pO2 58 mm Hg with 100% FiO2), atrial fibrillation, and hemodynamic instability. Echocardiography showed dilatation of right atrium and ventricle with a mean pulmonary artery pressure of 48 mm Hg. Computed tomographic scan revealed the presence of cement in the right and left pulmonary arteries and in several lobar and segmental arteries of superior and inferior lobes (Fig 1A), in the inferior vena cava, and in the perivertebral venous system (Fig 1B). Renal function was also impaired with creatinine values that went up to 400 µmol/L, probably due to the gentamicine contained in the cement. The patient received noninvasive ventilatory support, inotropic agents, and heparin (aPTT 60 ÷ 80 seconds), but after 48 hours, cardiac and respiratory functions did not improve. Therefore, pulmonary embolectomy was performed under extracorporeal circulation through median sternotomy. The left and right pulmonary arteries were opened and, since cement was not glued to the vessel wall (Fig 2) 9 g of cement (Fig 3) were easily removed. Despite anticoagulation, thrombi covered most of the acrylic surface. The Robicsek technique was used for the sternum osteosynthesis. On the 1st postoperative day, the patient had no rest dyspnea, SpO2 95%, pO2 98 mm Hg with 21 O2/min, sinus rhythm, and mean pulmonary artery pressure of 26 mm Hg. Creatinine was still high (343 µmol/L) 10 days after the vertebroplasty, but diuresis was normal. The patient was discharged 10 days after the thrombectomy with oral anticoagulation for 3 months.



View larger version (65K):
[in this window]
[in a new window]
  		Fig 1. Native computed tomographic scan of patient with osteogenesis imperfecta who underwent acrylic vertebroplasty complicated by pulmonary embolism. Acrylic cement is detected in the right and left pulmonary arteries (A), in lobar and segmental arteries of both lungs (A), and in the perivertebral venous system and in the inferior vena cava (B). (A) Reconstruction including the right and left pulmonary arteries showing the large Palacos deposits in the right pulmonary artery (large arrow) and with a lamellar distribution in the left pulmonary artery (thin arrow) and its branches. (B) An axial computed tomographic section at L5 level demonstrating acrylic cement filling the perivertebral veins and extending to the inferior vena cava (arrow).

 


View larger version (150K):
[in this window]
[in a new window]
  		Fig 2. Pulmonary embolectomy of Palacos injected 3 days before in vertebral bodies. Forceps kept the left pulmonary artery open and an acrylic string (arrow) floated inside.

 


View larger version (126K):
[in this window]
[in a new window]
  		Fig 3. Palacos removed from the right and left pulmonary arteries (total weight, 9 g).

 

   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Venous escape of cement has been frequently noted during vertebroplasty, but the great majority of these leaks are asymptomatic [2]. Three mechanisms seem to be the major determinants of cement embolism: (1) insufficient polymerization of the polymethyl methacrylate at the time of the injection which allows its migration into the inferior vena cava; (2) the needle position with respect to the basivertebral vein; (3) the overfill of the vertebral body that could facilitate cement migration into the venous system. Figure 1B shows the L5 body full of cement and the migration of the cement into the inferior vena cava through the perivertebral venous plexuses. This is probably due to the relatively slow polymerization of the polymethyl methacrylate with respect to the velocity of the injection and to the overfilling of the vertebral body. Some authors recommend the use of a barium-tungsten combination for adequate visualization of venous flow during fluoroscopy [1]. Two cases of cement pulmonary embolism related to percutaneous vertebroplasty [2, 3] and one case after hip replacement arthroplasty [4] have been reported in the literature. In all cases, anticoagulation was the treatment of choice, and patient outcome was considered favorable. Anticoagulation therapy reduces the risk of thrombus formation on the embolic material, but cannot reduce the right ventricle afterload and cannot improve the pulmonary ventilation-perfusion ratio, which is the cause of respiratory failure. This is the reason why we chose a more aggressive therapeutic strategy. Cement was easily removed from the pulmonary arteries since it was not glued to the vessel wall (Fig 2). We can speculate that the polymethyl methacrylate polymerization process was almost completed when it reached the arterial pulmonary system. This hypothesis is also supported by the shape of the fragments removed (Fig 3); none of them reproduces the vessel shape. We chose the Robicsek technique for the sternum osteosynthesis in order to reduce the risk of sternum instability which is extremely high in patients with osteogenesis imperfecta [5]. The patient underwent oral anticoagulation for 3 months to reduce the risk of thrombosis on the cement remaining in the distal part of the arterial pulmonary tree. In conclusion, we believe pulmonary embolectomy is one more therapeutic tool in critical patients. Although it could be dangerous to recommend any therapeutic approach based on a single case experience, pulmonary embolectomy appears to be a reliable and effective procedure in cases of severe respiratory and cardiac failure due to acrylic cement embolism in the main pulmonary trunks; it is the only treatment that could provide complete recovery from pulmonary and cardiac failure.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Jensen M.E., Avery J.E., Mathis J.M., Kallmes D.F., Cloft H.J., Dio J.E. Percutaneous polymethylmetacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. Am J Neuroradiol 1997;18:1897-1904.[Abstract]
  2. Padovani B., Kasriel O., Brunner P., Perretti-Viton P. Pulmonary embolism caused by acrylic cement: a rare complication of percutaneous vertebroplasty. Am J Neuroradiol 1999;20:375-377.[Abstract/Free Full Text]
  3. Perrin C., Jullien V., Blaive B. Percutaneous vertebroplasty complicated by pulmonary embolus of acrylic cement. Rev Mal Respir 1999;16:215-217.[Medline]
  4. Propst J.W., Siegel L.C., Schnittger I., Foppiano L., Goodman S.B., Brock-Utne J.G. Segmental wall motion abnormalities in patients undergoing total hip replacement: correlation with intraoperative events. Anesth Analg 1993;77:743-749.[Abstract/Free Full Text]
  5. Chevrel G., Meunier P.J. Osteogenesis imperfecta: lifelong management is imperative and feasible. Joint Bone Spine 2001;68:125-129.[Medline]



This article has been cited by other articles:


Home page
 Eur J EchocardiogrHome page
C. Cadeddu, S. Nocco, E. Secci, M. Deidda, R. Pirisi, and G. Mercuro
Echocardiographic accidental finding of asymptomatic cardiac and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty
Eur J Echocardiogr, June 1, 2009; 10(4): 590 - 592.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
Y. J. Kim, J. W. Lee, K. W. Park, J.-S. Yeom, H. S. Jeong, J. M. Park, and H. S. Kang
Pulmonary Cement Embolism after Percutaneous Vertebroplasty in Osteoporotic Vertebral Compression Fractures: Incidence, Characteristics, and Risk Factors
Radiology, April 1, 2009; 251(1): 250 - 259.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
K. H. Son, J. H. Chung, K. Sun, and H. S. Son
Cardiac perforation and tricuspid regurgitation as a complication of percutaneous vertebroplasty
Eur. J. Cardiothorac. Surg., March 1, 2008; 33(3): 508 - 509.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
S. H. Lim, H. Kim, H. K. Kim, and M.-J. Baek
Multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty
Eur. J. Cardiothorac. Surg., March 1, 2008; 33(3): 510 - 512.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Neuroradiol.Home page
J. Krebs, N. Aebli, B.G. Goss, K. Wilson, R. Williams, and S.J. Ferguson
Cardiovascular Changes after Pulmonary Cement Embolism: An Experimental Study in Sheep
AJNR Am. J. Neuroradiol., June 1, 2007; 28(6): 1046 - 1050.
[Abstract] [Full Text] [PDF]

Home page
 JBJSHome page
N. A. Manson and F. M. Phillips
Minimally Invasive Techniques for the Treatment of Osteoporotic Vertebral Fractures
J. Bone Joint Surg. Am., August 1, 2006; 88(8): 1862 - 1872.
[Full Text] [PDF]

Home page
 RadiologyHome page
H. M. Barragan-Campos, J.-N. Vallee, D. Lo, E. Cormier, B. Jean, M. Rose, P. Astagneau, and J. Chiras
Percutaneous Vertebroplasty for Spinal Metastases: Complications
Radiology, January 1, 2006; 238(1): 354 - 362.
[Abstract] [Full Text] [PDF]

Home page
 J Bone Joint Surg BrHome page
A. G. Hadjipavlou, M. N. Tzermiadianos, P. G. Katonis, and M. Szpalski
Percutaneous vertebroplasty and balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures and osteolytic tumours
J Bone Joint Surg Br, December 1, 2005; 87-B(12): 1595 - 1604.
[Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
S. Y. Kim, J. B. Seo, K.-H. Do, J. S. Lee, K.-S. Song, and T.-H. Lim
Cardiac Perforation Caused by Acrylic Cement: A Rare Complication of Percutaneous Vertebroplasty
Am. J. Roentgenol., November 1, 2005; 185(5): 1245 - 1247.
[Full Text] [PDF]

Home page
 Eur Respir JHome page
B. Vandooren, C. Haenebalcke, and Y. Bogaerts
Two patients with the same type of iatrogenic disease
Eur. Respir. J., February 1, 2005; 25(2): 389 - 391.
[Full Text] [PDF]

Home page
 Chest MeetingHome page
J. Simon Grahe, L. Casey, and G. White
Pulmonary Cement Embolism Following Percutaneous Vertebroplasty
Chest Meeting Abstracts, October 1, 2004; 126(4): 956S - 956S.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
D. H. Choe, E. M. Marom, K. Ahrar, M. T. Truong, and J. E. Madewell
Pulmonary Embolism of Polymethyl Methacrylate During Percutaneous Vertebroplasty and Kyphoplasty
Am. J. Roentgenol., October 1, 2004; 183(4): 1097 - 1102.
[Abstract] [Full Text] [PDF]

Home page
 Anesth. Analg.Home page
K. Stricker, R. Orler, K. Yen, J. Takala, and M. Luginbuhl
Severe Hypercapnia Due to Pulmonary Embolism of Polymethylmethacrylate During Vertebroplasty
Anesth. Analg., April 1, 2004; 98(4): 1184 - 1186.
[Abstract] [Full Text] [PDF]

Home page
 Chest MeetingHome page
A. A. Elshinawy, D. A. White, and D. E. Stover
Hard Rock Arteries: A Case of a Post-operative Complication
Chest Meeting Abstracts, October 1, 2003; 124(4): 304S - 305.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tozzi, P.
Right arrow Articles by von Segesser, L. K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tozzi, P.
Right arrow Articles by von Segesser, L. K.
Related Collections
Right arrow Lung - other

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS