Pulmonary Artery Cement Embolization After Vertebral Augmentation Procedures

Abstract

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary artery (PA) cement embolus (CE) is an infrequently reported complication of vertebral augmentation procedures, including vertebroplasty and kyphoplasty, and has a reported rate between 3.5% and 23%.1,2 Cement can leak into the immediately surrounding vertebral venous system, through the azygous vein and right atrium, and into the PA system, where the PA-CE can cause acute pulmonary distress and detriment to the patient. CASE PRESENTATION: We present three cancer patients who developed PA-CE following vertebral augmentation procedures. Patient 1 (Pt1) presented with back pain attributed to multiple myeloma and underwent T9 and L4 kyphoplasty. On post-operative day (POD) 1, Pt1 complained of dyspnea and band-like chest pain with inspiration, was diagnosed by CT pulmonary angiogram with a left lower PA-CE, and was managed with dalteparin. Patient 2 (Pt2) presented with back pain attributed to metastatic breast carcinoma and underwent L2 corpectomy, followed by L1-L3 instrumented fusion and L1 and L3 vertebroplasty. Pt2 developed persistent tachycardia, dyspnea, and chest pain, was diagnosed on POD9 by CT pulmonary angiogram with a left lower PA-CE as well as by echocardiogram with a right atrial echogenic structure, and was managed with dalteparin initially, followed by enoxaparin for 2 months, and then rivaroxaban for another 2 months. Patient 3 (Pt3) presented with back pain attributed to multiple myeloma and underwent T8-T12 kyphoplasty, with L2 kyphoplasty 2 months later. Pt3 presented with pneumonia-like symptoms on POD74, was diagnosed by contrast CT scan with a right lower PA-CE, and underwent right lower lobectomy after an attempted PA embolectomy. DISCUSSION: PA-CE is unpredictable in onset and presentation and, therefore, a challenging diagnosis without imaging. Risk of cement extravasation is increased with low viscosity, increased pressure, and volume of cement injection.3 Intraoperative recommendations aim to reduce extravasation accordingly. Postoperative chest x-ray screening is recommended for all patients2,3, and treatment is recommended for symptomatic patients or patients with central emboli.2 Anticoagulation therapy for six months is preferred in most cases. However, surgery is indicated with large emboli and cardiopulmonary dysfunction.2 CONCLUSIONS: PA-CE is a clinically significant, although underreported, complication arising from vertebral augmentation procedures. As this complication has variable presentation and may follow a seemingly uncomplicated surgery, recognition may provide a challenge for clinicians. Reference #1: Habib, N. et al. Heart Lung J. Acute Crit. Care 41:509-511, 2012. Reference #2: Krueger, A. et al. Eur. Spine J. 18:1257-1265, 2009. Reference #3: Radcliff, K. E. et al. Spine J. 10:e1-e5, 2010. DISCLOSURE: The following authors have nothing to disclose: Adil Malik, Cristen Litz, Nam Tran, Carla Moodie, Joseph Garrett, Jacques-Pierre Fontaine, Eric Toloza No Product/Research Disclosure Information