Intravascular Cement Leak after Vertebroplasty Treated with Stent Graft Placement in the Inferior Vena Cava

Abstract

A 75-year-old man presented with a large amount of cement extravasation into the inferior vena cava (IVC) after undergoing L4-S1 surgical fusion with vertebroplasty for prostate cancer metastases. Cement extended from L4 to the suprarenal IVC (Fig 1). Given the risk for embolization, a decision was made to intervene. The brittle consistency of set cement raised concern for fracture and embolization during snaring maneuvers. It was decided to stabilize this cement column and exclude it from the flow lumen. Under general anesthesia, a 3-pronged approach was used. Through a 16-F internal jugular vein sheath, a Coda balloon (Cook, Inc, Bloomington, Indiana) was positioned in the suprahepatic IVC and inflated for flow interruption and embolic protection; the acute drop in preload was mitigated by aggressive fluid resuscitation with pressor support. A second Coda balloon positioned from the right groin was used to displace and compact the cement into the infrarenal IVC, allowing for deployment of a 32 mm × 57 mm Endurant II aortic extension stent graft (Medtronic, Minneapolis, Minneapolis) caudal to the renal veins, placed from a left groin access (Figs 2, 3). This stabilized most of the cement, excluding it from the flow lumen (Fig 4). Inadvertent embolization of a small piece of cement to the left lung occurred without clinical consequences (Fig 5). The patient was discharged on aspirin and clopidogrel. Six-month clinical follow-up was uneventful. The patient had no further embolization or IVC thrombosis on 1-month follow-up computed tomography (CT) (Fig 6). Figure 2Fluoroscopy image demonstrates undeployed stent graft placed from left femoral access (short arrow), positioned just caudal to lowest (right) renal vein—marked by wire placed from jugular approach (black arrow). The large cement piece extended from the level of L5 up to intrahepatic IVC (white arrows). Note an additional guide wire that had been advanced from a right common femoral vein access (asterisk). View Large Image Figure Viewer Download Hi-res image Figure 3A Coda balloon (black arrow) placed from the jugular access was inflated in the suprarenal IVC to interrupt blood flow and minimize embolization risk. A second Coda balloon placed from a right femoral access was inflated above the cement piece and pulled down to displace cement (white arrows) caudal to the ostia of the renal veins. Note a small fragment of cement that inadvertently broke off (short arrow), which was seen only retrospectively. View Large Image Figure Viewer Download Hi-res image Figure 4The stent graft was deployed in the infrarenal IVC while trapping most of the cement against the vein wall (white arrow). A wire placed from jugular access into the right renal vein courses through the uncovered portion of the stent graft (black arrow), designed for suprarenal fixation. View Large Image Figure Viewer Download Hi-res image Figure 5Fluoroscopy of the chest demonstrates a small cement fragment in the left lung (arrow) owing to embolization. View Large Image Figure Viewer Download Hi-res image Figure 6Coronal oblique multiplanar reformat from contrast-enhanced CT performed 1 month after procedure confirms exclusion of cement from the IVC lumen by the stent graft (white arrow) and patency of IVC and right renal vein draining through the uncovered portion of the stent graft (short arrow). The left renal vein was also patent, draining above the stent graft (not shown). Hyperdensities to the left of the IVC correspond to aortic atherosclerotic plaques (asterisk). View Large Image Figure Viewer Download Hi-res image