FATAL CENTRAL PULMONARY CEMENT EMBOLISM AFTER KYPHOPLASTY

Abstract

SESSION TITLE: Case Report Semifinalists 8 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: A 61-year old male presented to the emergency department with progressive shortness of breath two days after a kyphoplasty of T11-L1 due to a T12 fracture. The immediate post-operative course was uneventful. No post-procedure imaging was ordered and the patient was discharged to a rehabilitation center the day after surgery. CASE PRESENTATION: Vital signs showed a heart rate of 108 beats per minute, blood pressure of 130/87 mmHg, and temperature of 101 degrees Fahrenheit. Physical exam demonstrated a patient in respiratory distress with decreased breath sounds and crackles bilaterally on auscultation. Arterial blood gas demonstrated severe hypoxemia. An abdominal CT incidentally confirmed large polymethymethacrylate (PMMA) bone cement embolisms in both main pulmonary arteries and in a vertebral vein anterior to T11. He soon became obtunded with rapidly progressive hemodynamic and respiratory failure, was intubated and transferred to the intensive care unit. Despite all resuscitation efforts, he went into refractory shock necessitating vasopressors. Due to the ongoing progression of cardiac and hypoxemic respiratory failure and scarcity of therapeutic options, the patient was transferred to a hospital with a cardiothoracic surgery team for possible extra corporeal membrane oxygenation (ECMO) or surgical pulmonary artery embolectomy. After a safe transfer, the patient went into cardiopulmonary arrest while being evaluated and expired before he could benefit from any procedure. DISCUSSION: Pulmonary cement embolisms (PCE) are a complication of percutaneous vertebroplasty (PV) and balloon kyphoplasty procedures. In both procedures PMMA is injected into the body of the vertebra, either directly (vertebroplasty) or within an inflated balloon (kyphoplasty). Cement can leak into the vertebral vein, continue to the inferior vena cava and reach the pulmonary arteries. Fatalities due to PCE remain extremely rare, relate to PV, and occur during the procedure (3,6) or a few days after (7,8). Our case is, to our knowledge, the first fatality occurring in a kyphoplasty patient. CONCLUSIONS: No standardized treatment exists for PCE but many interventions are possible to retrieve larger emboli before they can become life threatening, if they are identified immediately (1,2,4,5). Additional studies should be conducted to identify patients at risk and avoid this occurrence. In the meantime, it seems reasonable to infer from past cases and our personal experience that routine intra-operative identification of leakages with fluoroscopy and post-operative CXR may be helpful in rapid recognition and treatment of this patient population before they become symptomatic and irreversibly hemodynamically unstable. Reference #1: 1. Barbero, S, et al. “Percutaneous Vertebroplasty: the Follow-up.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, Feb. 2008, www.ncbi.nlm.nih.gov/pubmed/18338131. Reference #2: 2. Baumann, A. et al. Cement Embolization into the Vena Cava and Pulmonal Arteries After Vertebroplasty: Interdisciplinary Management. European Journal of Vascular and Endovascular Surgery, Volume 31 , Issue 5 , 558 - 561 3. Chen, H L, et al. “A Lethal Pulmonary Embolism during Percutaneous Vertebroplasty.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, Oct. 2002, www.ncbi.nlm.nih.gov/pubmed/12351294/. 4. François, K, et al. “Successful Management of a Large Pulmonary Cement Embolus after Percutaneous Vertebroplasty: a Case Report.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, 15 Oct. 2003, www.ncbi.nlm.nih.gov/pubmed/14560098. Reference #3: 5. Li, Z, et al. “Cement Embolus Trapped in the Inferior Vena Cava Filter during Percutaneous Vertebroplasty.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, 2013, www.ncbi.nlm.nih.gov/pubmed/23690712. 6. Monticelli, F, et al. “Fatal Pulmonary Cement Embolism Following Percutaneous Vertebroplasty (PVP).” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, 20 Apr. 2005, www.ncbi.nlm.nih.gov/pubmed/15734107/. 7. Stricker, K, et al. “Severe Hypercapnia Due to Pulmonary Embolism of Polymethylmethacrylate during Vertebroplasty.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, Apr. 2004, www.ncbi.nlm.nih.gov/pubmed/15041623/. 8. Yoo, K Y, et al. “Acute Respiratory Distress Syndrome Associated with Pulmonary Cement Embolism Following Percutaneous Vertebroplasty with Polymethylmethacrylate.” Current Neurology and Neuroscience Reports., U.S. National Library of Medicine, 15 July 2004, www.ncbi.nlm.nih.gov/pubmed/15247590/. DISCLOSURES: No relevant relationships by Mariam Abboud, source=Web Response No relevant relationships by Brooke McDonald, source=Web Response