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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.



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  		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).

 


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  		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.

 


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  		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]



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