Abstract
Background
Vertebroplasty carries multiple complications due to the leakage of polymethylmethacrylate (PMMA) into the venous system through the iliolumbar or epidural veins. The rate of venous cement complications may vary from 1 to 10 %, with cement extravasation into the venous system in 24 % of patients. Emboli may further migrate into the right heart chambers and pulmonary arteries. Patients may vary in presentation from asymptomatic or symptoms such as syncope to life-threatening complications.
Case report
We present a case of a 57-year-old lady diagnosed with osteoporosis who underwent a staged antero–posterior fixation with PMMA vertebroplasty of progressive thoraco–lumbar kyphosis caused by osteoporotic fractures to T12, L1 and L2 vertebral bodies. Four weeks after the operation, the patient developed symptoms of left-sided chest pain, tachycardia and tachypnea. CT pulmonary angiogram (CTPA) found a high-density material within the right atrium, whilst ECHO demonstrated normal systolic function. The patient was commenced on enoxaparin at therapeutic dose of 1.5 mg/kg for 3 months and remained asymptomatic. Follow-up ECHO found no change to the heart function and no blood clot on the PMMA embolus.
Conclusions
Factors influencing the decision about conservative treatment included symptoms, localisation of the embolus, as well as time lapse between vertebroplasty and clinical manifestation. Patients that are commonly asymptomatic can be treated conservatively. The management of choice is anticoagulation with low-molecular-weight heparin or warfarin until the foreign body epithelialises and ceases in becoming potentially thrombogenic. Symptomatic patients with thrombi in the right atrium are commonly managed via percutaneous retrieval, whilst those with RV involvement or perforation are commonly managed with surgical retrieval. Management of individual patients should be based on individual clinical circumstances. Patients presenting with intracardiac bone cement embolism related to spinal procedures require thorough clinical assessment, cardiology input, and if required, surgical intervention.
Similar content being viewed by others
References
Martin DJ, Rad AE, Kallmes DF (2012) Prevalence of extravertebral cement leakage after vertebroplasty: procedural documentation versus CT detection. Acta Radiol (Stockholm, Sweden: 1987) 53:569–572. doi:10.1258/ar.2012.120222
Cotten A, Dewatre F, Cortet B, Assaker R, Leblond D, Duquesnoy B, Chastanet P, Clarisse J (1996) Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up. Radiology 200:525–530. doi:10.1148/radiology.200.2.8685351
Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE (1997) Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol 18:1897–1904
Vasconcelos C, Gailloud P, Beauchamp NJ, Heck DV, Murphy KJ (2002) Is percutaneous vertebroplasty without pretreatment venography safe? Evaluation of 205 consecutives procedures. AJNR Am J Neuroradiol 23:913–917
Dash A, Brinster DR (2011) Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty. Ann Thorac Surg 91:276–278. doi:10.1016/j.athoracsur.2010.06.106
Lim KJ, Yoon SZ, Jeon YS, Bahk JH, Kim CS, Lee JH, Ha JW (2007) An intraatrial thrombus and pulmonary thromboembolism as a late complication of percutaneous vertebroplasty. Anesth Analg 104:924–926. doi:10.1213/01.ane.0000256974.84535.7a
Pannirselvam V, Hee HT (2014) Asymptomatic cement embolism in the right atrium after vertebroplasty using high-viscosity cement: a case report. J Orthop Surg (Hong Kong) 22:244–247
Arnaiz-Garcia ME, Dalmau-Sorli MJ, Gonzalez-Santos JM (2014) Massive cement pulmonary embolism during percutaneous vertebroplasty. Heart 100:600. doi:10.1136/heartjnl-2013-304583
Caynak B, Onan B, Sagbas E, Duran C, Akpinar B (2009) Cardiac tamponade and pulmonary embolism as a complication of percutaneous vertebroplasty. Ann Thorac Surg 87:299–301. doi:10.1016/j.athoracsur.2008.05.074
Lee V, Patel R, Meier P, Lawrence D, Roberts N (2014) Conservative management of inferior vena cava cement spike after percutaneous vertebroplasty causes fatal cardiac tamponade. J Rheumatol 41:141–142. doi:10.3899/jrheum.130570
Mattis T, Knox M, Mammen L (2012) Intracardiac methylmethacrylate embolism resulting in right atrial wall perforation and pericarditis following percutaneous vertebroplasty. J Vasc Interv Radiol 23:719–720. doi:10.1016/j.jvir.2011.12.027
Park JH, Choo SJ, Park SW (2005) Images in cardiovascular medicine. Acute pericarditis caused by acrylic bone cement after percutaneous vertebroplasty. Circulation 111:e98. doi:10.1161/01.cir.0000155502.90653.a5
Son KH, Chung JH, Sun K, Son HS (2008) Cardiac perforation and tricuspid regurgitation as a complication of percutaneous vertebroplasty. Eur J Cardiothorac Surg 33:508–509. doi:10.1016/j.ejcts.2007.11.027
Grifka RG, Tapio J, Lee KJ (2013) Transcatheter retrieval of an embolized methylmethacrylate glue fragment adherent to the right atrium using bidirectional snares. Catheter Cardiovasc Interv 81:648–650. doi:10.1002/ccd.24333
Farahvar A, Dubensky D, Bakos R (2009) Perforation of the right cardiac ventricular wall by polymethylmethacrylate after lumbar kyphoplasty. J Neurosurg Spine 11:487–491. doi:10.3171/2009.5.spine08517
Gosev I, Nascimben L, Huang PH, Mauri L, Steigner M, Mizuguchi A, Shah AM, Aranki SF (2013) Right ventricular perforation and pulmonary embolism with polymethylmethacrylate cement after percutaneous kyphoplasty. Circulation 127:1251–1253. doi:10.1161/circulationaha.112.144535
Kim HT, Kim YN, Shin HW, Kim IC, Kim H, Park NH, Choi SY (2013) Intracardiac foreign body caused by cement leakage as a late complication of percutaneous vertebroplasty. Korean J Intern Med 28:247–250. doi:10.3904/kjim.2013.28.2.247
Kim SY, Seo JB, Do KH, Lee JS, Song KS, Lim TH (2005) Cardiac perforation caused by acrylic cement: a rare complication of percutaneous vertebroplasty. AJR Am J Roentgenol 185:1245–1247. doi:10.2214/ajr.04.1443
Moon MH, Jo KH, Kim HW (2013) Cardiac perforation caused by bone cement embolism. Arch Cardiovasc Dis 106:413–414. doi:10.1016/j.acvd.2011.11.010
Tran I, Gerckens U, Remig J, Zintl G, Textor J (2013) First report of a life-threatening cardiac complication after percutaneous balloon kyphoplasty. Spine 38:E316–E318. doi:10.1097/BRS.0b013e318281507a
Bose R, Choi JW (2010) Successful percutaneous retrieval of methyl methacrylate orthopedic cement embolism from the pulmonary artery. Catheter Cardiovasc Interv 76:198–201. doi:10.1002/ccd.22496
Minelli C, Kikuta A, Tsud N, Ball MD, Yamamoto A (2008) A micro-fluidic study of whole blood behaviour on PMMA topographical nanostructures. J Nanobiotechnol 6:3. doi:10.1186/1477-3155-6-3
Benneker LM, Krebs J, Boner V, Boger A, Hoerstrup S, Heini PF, Gisep A (2010) Cardiovascular changes after PMMA vertebroplasty in sheep: the effect of bone marrow removal using pulsed jet-lavage. Eur Spine J 19:1913–1920. doi:10.1007/s00586-010-1555-y
Clamp JA, Bayley EJ, Ebrahimi FV, Quraishi NA, Boszczyk BM (2012) Safety of fluoroscopy guided percutaneous access to the thoracic spine. Eur Spine J 21(Suppl 2):S207–S211. doi:10.1007/s00586-012-2201-7
Ding J, Zhang Q, Zhu J, Tao W, Wu Q, Chen L, Shi P, Zhang H (2015) Risk factors for predicting cement leakage following percutaneous vertebroplasty for osteoporotic vertebral compression fractures. Eur Spine J. doi:10.1007/s00586-015-3923-0
Chandra RV, Yoo AJ, Hirsch JA (2013) Vertebral augmentation: update on safety, efficacy, cost effectiveness and increased survival? Pain Physician 16:309–320
Krueger A, Bliemel C, Zettl R, Ruchholtz S (2009) Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J 18:1257–1265. doi:10.1007/s00586-009-1073-y
Righini M, Sekoranja L, Le Gal G, Favre I, Bounameaux H, Janssens JP (2006) Pulmonary cement embolism after vertebroplasty. Thromb Haemost 95:388–389
Wakhloo AK, Tio FO, Lieber BB, Schellhammer F, Graf M, Hopkins LN (1995) Self-expanding nitinol stents in canine vertebral arteries: hemodynamics and tissue response. AJNR Am J Neuroradiol 16:1043–1051
Novitzke J (2009) A patient guide to brain stent placement. J Vasc Interv Neurol 2:177–179
Braiteh F, Row M (2009) Right ventricular acrylic cement embolism: late complication of percutaneous vertebroplasty. Heart 95:275. doi:10.1136/hrt.2008.158790
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
None.
Rights and permissions
About this article
Cite this article
Hatzantonis, C., Czyz, M., Pyzik, R. et al. Intracardiac bone cement embolism as a complication of vertebroplasty: management strategy. Eur Spine J 26, 3199–3205 (2017). https://doi.org/10.1007/s00586-016-4695-x
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-016-4695-x