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It Should Not Be Here! A Strange Case of Pulmonary Cement Embolism Following Balloon Kyphoplasty FREE TO VIEW

Navneet Kumar, MD; Meenal Malviya, MD; Mario De Meireles, MD
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Providence Hospital and Medical Center, Southfield, MI

Chest. 2014;145(3_MeetingAbstracts):559A. doi:10.1378/chest.1826525
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SESSION TITLE: Miscellaneous Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Percutaneous balloon kyphoplasty is a safer treatment option of compression fractures, especially in elderly patients. Cement (polymethylmethacrylate or PMM) leakage is most common complication which may rarely cause pulmonary cement embolism. We report a case of elderly woman with cement pulmonary embolism 4 days following balloon kyphoplasty.

CASE PRESENTATION: A 90 year-old Caucasian lady with complex medical history of chronic lymphocytic leukemia (CLL), systemic hypertension and osteoporosis presented with increasing shortness of breath since 1 day for which she went to her cardiologist office. She was then sent to emergency room for further workup. Her vitals were stable with 96% oxygen saturation on room air. No other symptoms. Chest CT angiogram was done with contrast since she recently underwent successful uncomplicated balloon kyphoplasty of T9 & T10 vertebrae 4 days ago for pathologic fractures. CT showed hyperdense material within right upper, middle & lower lobe and left upper lobe pulmonary arteries consistent with cement pulmonary embolism. Also seen was hyperdense material in perivertebral venous system. However, X-rays done post-operatively showed cement to be in good position. Her echocardiogram showed left ventricular ejection fraction of 60% with normal right heart. She was then started on heparin and bridged to warfarin with target INR 2-3. She did have few episodes of non-sustained ventricular tachycardia and atrial arrhythmias which resolved on its own. Her vitals were stable when she was discharged to home after 5 days.

DISCUSSION: PMM cement has been widely used in various orthopedic and neurosurgical procedures since more than 25 years. Although percutaneous balloon kyphoplasty is a relatively safe procedure, local cement leaks are seen in 80% of cases. It can also leak into perivertebral veins from where it can rarely embolise in the pulmonary arteries. There is no consensus in management guidelines with some authors suggesting conservative approach (careful observation) while others suggest surgical embolectomy or percutaneous removal. In our patient because of her co-morbid conditions she was deemed a poor candidate for surgery. We felt that there is increased risk of platelet aggregation and clot formation on the cement in pulmonary arteries and we decided to do long term anticoagulation.

CONCLUSIONS: Our case shows the need to consider pulmonary cement embolism in patients, especially with pathological fractures, who have undergone balloon kyphoplasty recently and present with increased shortness of breath.

Reference #1: Geraci G, et al. Asymptomatic bone cement pulmonary embolism after vertebroplasty: Case repost and review of literature. Case Reports in Surgery. 2013 march. Ahead of print.

DISCLOSURE: The following authors have nothing to disclose: Navneet Kumar, Meenal Malviya, Mario De Meireles

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