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Cardiothoracic Surgery |

Emergent Embolectomy for Massive Intraoperative Thromboembolism During Total Artificial Hip Replacement

Moritz Wyler Von Ballmoos, MD; G Almassi, MD; Sweeta Gandhi, MD
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Medical College of Wisconsin/Milwaukee, WI, Milwaukee, WI


Chest. 2015;148(4_MeetingAbstracts):33A. doi:10.1378/chest.2280176
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Abstract

SESSION TITLE: Cardiothoracic Surgery Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Thromboembolism is a known complication after orthopedic surgery but rarely occurs intraoperatively. Cement embolism during the procedure is less common but can be fatal. While the diagnosis is readily made, management may be controversial as there is no current consensus regarding optimal treatment. We present such a case requiring emergent embolectomy assisted by cardiopulmonary bypass.

CASE PRESENTATION: A 64-year old man with a history of COPD and alcohol abuse presented with streptococcus pneumonia and a complex fracture of the hip, necessitating total artificial hip replacement. After initial medical management and conservative treatment of the fracture the patient was scheduled for elective surgery. During that procedure, at the time of bone cement injection, the patient abruptly developed hemodynamic instability and PEA. CPR was initiated, while thromboembolism was confirmed by TEE. An emergency sternotomy was performed and the patient was placed on cardiopulmonary bypass for removal of massive clot extending from the IVC through the RV into the pulmonary arteries (Fig. 1). An IVC filter was also placed to prevent further thromboembolism.

DISCUSSION: Massive thromboembolism was provoked by cement leak into circulation in this patient who had other risk factors including a recent infection and prolonged immobilization. Particles of bone cement were found in the removed clot on surgical pathology.

CONCLUSIONS: The incident of massive and fatal thromboembolism in perioperative patients is reported as 0.1-2% after most procedures, but as high as 13% after hip replacement[1]. This case illustrates diagnosis and treatment, including emergent pulmonary embolectomy, in patients presenting with major intraoperative thromboembolism, which is a rare but often fatal complication during surgery. Patients undergoing bone cement injection are particularly at risk for this entity.

Reference #1: Geerts WH, Bergqvist D, Pineo GF, et al. American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):381S-453S.

DISCLOSURE: The following authors have nothing to disclose: Moritz Wyler Von Ballmoos, G Almassi, Sweeta Gandhi

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