SESSION TITLE: Pulmonary Vascular Disease Cases
SESSION TYPE: Case Reports
PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM
INTRODUCTION: Percutaneous vertebroplasty and kyphoplasty are both techniques used to treat vertebral fractures and consist in the application of polimethilmethacrilate (PMMA) into the vertebral body, working as cement. One of the complications is pulmonary embolism (PE) of PMMA due to leakage of cement into the perivertebral veins. We report one case of a patient with cement PE seen in our practice.
CASE PRESENTATION: A 50 year-old-woman, non-smoker, with history of vertebroplasty of L5 four years before, referred to our consult because of an abnormal chest radiograph. The patient reported that in the last four years had noticed effort dyspnea, chest pain and palpitation episodes. Physical examination was normal. Chest X-ray revealed a hyperdense foreign body in the left pulmonary artery and similar lineal images in contralateral hemithorax. Thorax/abdomen computer tomography (CT) scan confirmed the presence of a calcium-density foreign body in left pulmonary artery and in multiple peripheral arteries of right lung. In addition, at L5 level, there was a lineal hyperdensity, that started from the cement of the L5 vertebral body and extended into the left common iliac vein. The diagnosis was cement pulmonary embolism, secondary to vertebroplasty intervention. Treatment was not given, observation follow-ups for the next three years were made, and the patient did not present clinical or radiology changes.
DISCUSSION: Cement PE due to vertebroplasty frequency reported in case series has a range between 3.4% and 23%, and in most of the cases curses asymptomatic, probably making this complication under-diagnosed. Even though there are case reports, case series and reviews in the literature, the quality of these studies is not enough to determine a clear treatment strategy. Treatment is based on the presence or absence of symptoms and emboli location. Observation is recommended in case of asymptomatic patient, 3 to 6-month-anticoagulation in symptomatic or in patients with central emboli, or surgery in severe cases.
CONCLUSIONS: The incidence of cement pulmonary embolism is probably underestimated due to asymptomatic cases. Chest X-ray after the intervention is recommended. Further and better studies are needed to clear up treatment strategies; meanwhile recommendations made from the available literature should be followed
Reference #1: Krueger A, Bliemel C, Zettl R, Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J. 2009 Sep;18(9):1257-65.
Reference #2: Abdul-Jalil Y, Bartels J, Alberti O, Becker R. Delayed presentation of pulmonary polymethylmethacrylate emboli after percutaneous vertebroplasty. Spine 2007;32(20):E589-93.
DISCLOSURE: The following authors have nothing to disclose: Aarón Córdova, Inma Alfageme
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