CAN CEMENT TAKE OUR BREATH AWAY? AN INTERESTING CASE OF PULMONARY EMBOLISM AFTER KYPHOPLASTY

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pulmonary cement embolism (PCE) refers to embolization of polymethyl methacrylate into the lungs. Patients are most often asymptomatic, but reports have been made were patients present symptomatically after PCE. We report a case of a 61-year-old man who had a vertebral kyphoplasty and presented 2 days later with acute onset respiratory distress and found to have a fatal PCE in the setting of multiple comorbidities. CASE PRESENTATION: 61-year-old male with medical history of HIV, DM, HTN, ESRD on HD, presented with worsening back pain. The back pain started after a mechanical fall. Imaging revealed a T12 burst fracture.Patient underwent an uncomplicated kyphoplasty of T11, T12, L1 vertebrae, did well post-operatively and was discharged. Patient presented back to ED on same day of discharge with complaints of acute onset shortness of breath. On arrival, Patient appeared in severe respiratory distress. His physical examination was remarkable for decreased breath and crackles bilaterally. Due to increased work of breathing, he was intubated and placed on mechanical ventilation in the ED. Initial CXR showed increased hyperdense perihilar opacities. The clinical presentation was concerning for embolic vertebroplasty material (IMG1). This was confirmed with a CTA (IMG2) which reported extensive vertebroplasty cement embolism to the pulmonary arteries and enlargement of the pulmonary arteries. Patient was admitted to the ICU for mechanical ventilation and open cardiac surgery to remove cement from the lungs was considered, but patients status continued to deteriorate in the following 24 hours. He was hemodynamically unstable requiring large doses of vasopressors and requiring immediate hemodialysis. Patient had an episode of PEA arrest after which family decide to withdraw care. DISCUSSION: In this case, a Chest X ray showed pulmonary infiltrates and an increase in perihiliar opacities compatible with embolic vertebroplasty at the ER after 72 hours post procedure. Although most patients remain asymptomatic according to different authors, it has been reported cases in which patients develop symptoms months, and even until 10 years after procedure. PCE after kyphoplasty is a complication that happens according to different series as low as 3.5% up to high as 28.6% . Percutaneous kyphoplasty has been reported with less possibility to develop Pulmonary cement embolism than vertebroplasty. The presence of comorbidities in a patient of the older age increased the possibilities of fatal outcome in this patient. CONCLUSIONS: Percutaneous kyphoplasty one of the main complications of this procedure has been the development of PCE which if detected early with a high index of suspicion has an overall good prognosis. In those patients with serious co-morbidities and kyphoplasty, closer monitoring should be done in order to detect the onset of symptoms and to provide adequate treatment to avoid fatal outcomes. Reference #1: M.I. Syed, S. Jan, N.A. Patel, A. Shaikh, R.A. Marsh, R.V. Stewart. Fatal Fat Embolism after Vertebroplasty: Identification of the High-Risk Patient. American Journal of Neuroradiology Feb 2006, 27 (2) 343-345. Reference #2: Dash A, Brinster DR. Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty. Annals of Thoracic Surgery. 2011;91(1):276–278 Reference #3: Nishant Sinha, Vivek Padegal, Satish Satyanarayana,and Hassan Krishnamurthy Santosh. Pulmonary cement embolization after vertebroplasty, an uncommon presentation of pulmonary embolism: A case report and literature review DISCLOSURES: No relevant relationships by Gustavo Avila, source=Web Response no disclosure on file for Yash Jobanputra; No relevant relationships by Purva Sharma, source=Web Response