SESSION TITLE: Pulmonary Vascular Disease Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Monday, October 26, 2015 at 03:15 PM - 04:15 PM
INTRODUCTION: Acrylic kyphoplasty involves percutaneous reduction of a vertebral body fracture with balloon compression followed by injection of polymethylmethacrylate (PMMA) cement (1). Intravascular embolization of PMMA cement is a known complication (2). Prior case reports suggest surgical thrombectomy in symptomatic patients with central pulmonary embolisms (3). We report an alternative approach using a fluoroscopy guided snare to remove a central pulmonary embolism percutaneously.
CASE PRESENTATION: A 41 year old male with a prior un-witnessed seizure complicated by endplate vertebral fractures was admitted for kyphoplasty. During injection of PMMA cement under fluoroscopy, a larger than usual amount of cement was observed to migrate out of the T7 vertebral body via an emissary vein and into the pulmonary vasculature. Computed tomography confirmed PMMA embolism within the truncus anterior. An echocardiogram showed no evidence of right heart strain. The patient remained hemodynamically stable. Post-procedure, the patient reported shortness of breath with movement. His oxygen saturation on room air was 88%. Full dose anticoagulation was initiated and IR guided embolectomy was attempted. Using femoral venous access, a catheter was placed proximal to the filling defect. A 20mm loop snare was then used to retrieve the cement embolism. The patient's exercise tolerance gradually improved and he was discharged home off anticoagulation.
DISCUSSION: PMMA leakage after acrylic kyphoplasty is a common complication that can occur if the PMMA is too liquid or if too much pressure is applied during injection (2). Intravascular embolization is a known risk, although pulmonary embolism occurs less frequently, with an incidence ranging from 3.5-23% (2). Prior literature suggests surgical thrombectomy in symptomatic patients with central embolisms (3) and anticoagulation in any symptomatic embolism (2). To our knowledge, this is the first reported percutaneous removal of a symptomatic central embolism that lead to resolution of symptoms and successful discharge off anticoagulation. We recommend consideration of this approach in all patients with central symptomatic emboli following vertebral kyphoplasty.
CONCLUSIONS: Fluoroscopy guided percutaneous removal of PMMA cement pulmonary embolisms should be considered as alternative to surgical thrombectomy in symptomatic patients.
Reference #1: Radcliff et al. Spine J. 2010;10(10):e1-5.
Reference #2: Krueger et al. Eur Spine J. 2009;18(9):1257-1265.
Reference #3: Tozzi et al. Ann Thorac Surg. 2002;74:1706-1708.
DISCLOSURE: The following authors have nothing to disclose: Daniel Burke, Darya Rudym, Anthony Lubinksy
To our knowledge, we are reporting the first percutaneous, fluoroscopy guided removal of a polymethylmethacrylate cement pulmonary embolism as an alternative to surgical thrombectomy.