SESSION TITLE: Cardiovascular Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Cement pulmonary artery emboli are a known complication following vertebral kyphoplasty with incidence thought to occur between 2.1 to 26% of patients undergoing this procedure. We present a case of cement pulmonary artery emboli and review of current preventative and treatment guidelines.
CASE PRESENTATION: A 39-year-old woman with a history of asthma and degenerative joint disease with a resultant L4-S1 vertebral kyphoplasty four years prior presented with complaints of dyspnea. Her dyspnea was sudden onset and occurred at rest following extensive travel. She also experienced diffuse pleuritic chest pain that was accompanied by a dry cough. She had tried her albuterol inhaler at home without relief and was also given an albuterol nebulizer in the Emergency Room without improvement in her dyspnea. Her vital signs were within normal limits including her oxygen saturation. She was in mild distress and wheezing, without crackles on auscultation of her respiratory system. There was no lower extremity edema or erythema. On laboratory examination she was noted to have a mildly elevated D-dimer of 0.62mcg/mL. An electrocardiogram was normal and a chest radiograph had no acute cardiopulmonary disease process. Since her symptoms did not respond to therapy and she had an elevated D-dimer, a helical computerized tomography of the chest was performed that demonstrated multiple bilateral cement pulmonary artery emboli. She improved with therapy for obstructive lung disease and was initated on enoxaparin for anticoagulation.
DISCUSSION: Cement emboli occurs during a vertebral kyphoplasty, as there is an injection of polymethylmethacrylate into the vertebral bodies that can result in extravasations into the paravertebral veins resulting in pulmonary emboli. It can also extravasate into the paravertebral veins as a result of too much pressure being applied to the vertebral bodies during the kyphoplasty. Importantly ensuring the injected material is of toothpaste like texture can decrease embolization.
CONCLUSIONS: Current treatment guidelines recommend the use of anticoagulation with warfarin for six months. There have been reports of endothelialization after six months of warfarin therapy is completed to prevent the progression of the embolus. However if the cement pulmonary emboli are found incidentally or the patient is asymptomatic, no further treatment is indicated.
Reference #1: Krueger A, Bliemel C, Zettl R, Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systemic review of the literature. Eur Spine J. 2009;18(9): 1257-1265.
Reference #2: Abdul-Jalil Y, Bartels J, Alberti O, Becker R. Delayed presentation of pulmonary polymethylmethacrylate emboli after percutaneous vertebroplasty. Spine. 2007;32:E589-E593.
Reference #3: Sifuentes G et al. Cement pulmonary embolism after vertebroplasty. Rheumatol Clin. 2013 Mar 4. pii: S1699-258X(12)00249-5. doi: 10.1016
DISCLOSURE: The following authors have nothing to disclose: Prateek Sanghera, Sarah Andrews, Vivek Sambhara, Fred Garfinkel, Victor Test
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