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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 64-67

Surgical extraction of a delayed symptomatic polymethylmethacrylate cement pulmonary embolism: A case report and discussion of surgical therapy


Department of Surgery, Summa Health System, Akron, OH 44304, USA

Date of Submission23-Apr-2017
Date of Acceptance09-Apr-2017
Date of Web Publication23-Apr-2018

Correspondence Address:
Dr. Michael S Firstenberg
Department of Cardiothoracic Surgery, Summa Health System, 75 Arch Street, No. 407, Akron, OH 44304
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_50_17

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  Abstract 


Pulmonary cement embolization (PCE) is a rare but significant complication of vertebroplasty surgery. The management of this process is not well studied and depends on the extent and duration of symptoms. Here, a case of 68-year-old woman is presented who was found to have a symptomatic PCE involving the left main pulmonary artery 9 months after a kyphoplasty surgery was performed with polymethylmethacrylate. She was successfully managed surgically by the left main pulmonary embolectomy with complete symptomatic resolution postoperatively.
The following core competencies are addressed in this article: Patient care, Medical knowledge.

Keywords: Kyphoplasty, polymethylmethacrylate, pulmonary cement embolization, pulmonary embolectomy


How to cite this article:
Morgan SA, Martin AM, Firstenberg MS. Surgical extraction of a delayed symptomatic polymethylmethacrylate cement pulmonary embolism: A case report and discussion of surgical therapy. Int J Acad Med 2018;4:64-7

How to cite this URL:
Morgan SA, Martin AM, Firstenberg MS. Surgical extraction of a delayed symptomatic polymethylmethacrylate cement pulmonary embolism: A case report and discussion of surgical therapy. Int J Acad Med [serial online] 2018 [cited 2020 Sep 22];4:64-7. Available from: http://www.ijam-web.org/text.asp?2018/4/1/64/230846




  Introduction Top


While, thromboembolic events are the most common causes of pulmonary embolism, other biologic and nonbiologic materials have been known to embolize to the pulmonary arteries. Symptoms can vary from vague chest discomfort to cardiopulmonary collapse and death. Management options are often based on the symptoms and nature of the embolic material. However, in some cases, the options are less clearly defined. Typically, iatrogenic embolic complications are encountered with intravascular access wires or devices. However, iatrogenic pulmonary embolism after the injection of biologic cements during spinal procedures, such as kyphoplasties or vertebroplasties, has been described – but rarely encountered, especially as a source of chronic symptoms. As such, we present an unusual case of pulmonary embolism with polymethylmethacrylate (PMMA) following kyphoplasty and describe the rationale and techniques for surgical management.


  Case Report Top


Our patient is a 68-year-old female with a history of a pulmonary embolism 30 years prior who presented with a 3-month history of pleuritic chest pain, chronic cough, and exertional dyspnea. Nine months before the presentation, she underwent a kyphoplasty of L1 and L4 for symptomatic compression fractures in which PMMA was used to fill the vertebral bodies. According to the operative note, only 2 ml of PMMA was injected. A computed tomography angiography (CTA) was performed and revealed a radiopaque mass in her left main pulmonary artery several centimeters distal from the main bifurcation. The lesion was hyperdense, elliptical, and irregular. It appeared to be directly abutting a major bronchus [Figure 1]. Several smaller lesions located in the distal branches of the left pulmonary artery were also concerning for emboli. Angiography showed a density with sharp-appearing edges overlying the pulmonary vasculature with a filling defect of the left pulmonary artery [Figure 2]. While the etiology was unclear, there was concern that the mass represented either residual calcification from her previous pulmonary emboli or a pulmonary cement embolization (PCE) given her history of kyphoplasty. After a multidisciplinary discussion involving interventional cardiology, interventional radiology, pulmonology, and cardiothoracic surgery, the decision was made to proceed with direct surgical extraction due to the concern for potential airway or vascular erosion, pseudoaneurysm formation, nidus for further emboli, and potential source of infection. In addition, the patient was extremely anxious about the mass in her pulmonary artery. Considering her concerns for recurrence of her thrombotic embolism, she expressed significant interest in having the embolus removed. Preoperative cardiac catheterization and echocardiography were unremarkable.
Figure 1: Computed tomography angiography chest demonstrating embolism

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Figure 2: Angiogram of chest demonstrating embolism

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The surgical approach consisted of a standard median sternotomy. Following routine heparinization, cardiopulmonary bypass was initiated with standard ascending aorta and right atrial cannulation. Myocardial protection was achieved with antegrade cardioplegia and topical cold saline. Following aortic cross-clamping and myocardial arrest, a vertical incision was made in the main pulmonary artery and extended down toward the left pulmonary artery. The mass was clearly visualized in the distal left main pulmonary artery and was adherent to the endocardial surface. It was extracted, in a single piece (2 cm × 1 cm × 1 cm), with gentle traction/counter-traction with Kelly forceps. On examination the mass was hard and white in color [Figure 3]. No obvious arterial luminal defects were identified following the extraction. The pulmonary artery was closed primarily with running 4-0 monofilament suture. The patient was weaned from cardiopulmonary bypass under transesophageal echocardiographic guidance, the heparin was reversed, and she was decannulated. The chest was closed in a standard fashion. Total bypass time was 26 min, and cross-clamp time was 21 min.
Figure 3: Photo of embolic foreign body

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Postoperatively, the patient was extubated within 6 h after the procedure. She was discharged home on postoperative day 5 following an uneventful hospital course. Clopidogrel was empirically prescribed for pulmonary thrombotic prophylaxis. At 2-week follow-up, she reported complete resolution of her chest pain, dyspnea, and chronic cough.

Pathologic evaluation of the surgical specimen showed an elongated fragment of the vascular wall mixed with fibrin thrombus showing early organization in the background of foreign crystalline material. The crystalline material under polarized light was consistent with PMMA. These findings were consistent with PCE.


  Discussion Top


Injection of PMMA, also known as bone cement or acrylic, into the vertebral column is often performed in vertebroplasty and kyphoplasty procedures. These procedures are commonly performed for the treatment of vertebral osteoporosis and compression fractures of the vertebral column with the goal of reducing back pain and preventing further vertebral body collapse. PCE is a rare and alarming complication of vertebroplasty or kyphoplasty performed with PMMA. The proposed mechanism of PCE is from the extravasation of bone cement into the vertebral venous plexus while it is in the liquid phase.[1] From the venous plexus, the cement travels into the thoracic venous system and into the pulmonary circulation causing cement pulmonary embolism.[2] The liquid eventually solidifies into rigid cement. The majority of patients with cement embolization are asymptomatic and presumably go undiagnosed.[3] Some patients with PCE have clinical symptoms including chest pain, dyspnea, cough, lightheadedness, and dizziness. Less commonly, PCE can cause significant hypotension and right heart strain similar to a massive pulmonary embolism. PCE has also been linked to the development of acute respiratory distress syndrome;[4] and most concerning; it has been associated with multiple deaths.[5],[6],[7]

Treatment strategies for immediately recognized PCE include observation, systemic anticoagulation, percutaneous removal, and surgical removal.[8] Although there is limited data to support formal management guidelines, recent recommendations suggest observation for asymptomatic individuals with peripheral embolisms.[8],[9] For symptomatic lesions, treatment options range from an extended trial of anticoagulation to emergent surgical intervention in hemodynamically unstable patients.[8] Percutaneous retrieval of PCE has been described in the literature but not for large or chronic lesions.[10] Emergent surgical pulmonary embolectomy has been described in the cases of PCE causing severe hypotension and right heart dysfunction.[11] Pulmonary wedge resection with pulmonary embolectomy has been described as the treatment for a massive PCE causing pulmonary infarction.[12] While pulmonary embolectomy is an established therapy for acute pulmonary thromboembolism, similar techniques have not been extensively reported for the treatment of chronic PCE.[13],[14]


  Conclusion Top


This case report presents a case of a 68-year-old female with what appeared to be a calcified mass consistent with a symptomatic PCE seen on chest CTA 9 months after a kyphoplasty performed with PMMA. While, there was no evidence of progressing pulmonary occlusion and she was clinically stable, there were concerns for her persistent symptoms, as well as the theoretical risk for the large, rigid mass potentially causing bronchial or vascular erosion, pseudoaneurysm, or serving as a nidus for infection or pulmonary embolism. Due to the size of the mass and its irregular shape with sharp edges, it was felt that an attempt at percutaneous extraction was dangerous and could injure the pulmonary vasculature, pulmonic valve, or tricuspid valve. She was therefore treated by left main pulmonary embolectomy, and the lesion was removed with no complications. She experienced complete resolution of her symptoms postoperatively. Surgical pulmonary embolectomy has been performed extensively and has been shown to be safe for the treatment of acute pulmonary thromboembolism. We believe pulmonary embolectomy is a safe and reasonable approach to patients with symptomatic PCE, even if presenting in a delayed fashion.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent documentation, wherein the patient(s) has/ have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patient(s) understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We appreciate the support of the Summa Health System Department of Radiology and Akron Radiology Inc., for support in image interpretation and image preparation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Groen RJ, du Toit DF, Phillips FM, Hoogland PV, Kuizenga K, Coppes MH, et al. Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: A reappraisal of the vertebral venous system. Spine (Phila Pa 1976) 2004;29:1465-71.  Back to cited text no. 1
    
2.
Teng MM, Cheng H, Ho DM, Chang CY. Intraspinal leakage of bone cement after vertebroplasty: A report of 3 cases. AJNR Am J Neuroradiol 2006;27:224-9.  Back to cited text no. 2
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3.
Luetmer MT, Bartholmai BJ, Rad AE, Kallmes DF. Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty. AJNR Am J Neuroradiol 2011;32:654-7.  Back to cited text no. 3
[PUBMED]    
4.
Habib N, Maniatis T, Ahmed S, Kilkenny T, Alkaied H, Elsayegh D, et al. Cement pulmonary embolism after percutaneous vertebroplasty and kyphoplasty: An overview. Heart Lung 2012;41:509-11.  Back to cited text no. 4
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5.
Yoo KY, Jeong SW, Yoon W, Lee J. Acute respiratory distress syndrome associated with pulmonary cement embolism following percutaneous vertebroplasty with polymethylmethacrylate. Spine (Phila Pa 1976) 2004;29:E294-7.  Back to cited text no. 5
    
6.
Chen HL, Wong CS, Ho ST, Chang FL, Hsu CH, Wu CT, et al. Alethal pulmonary embolism during percutaneous vertebroplasty. Anesth Analg 2002;95:1060-2.  Back to cited text no. 6
    
7.
Franco E, Frea S, Solaro C, Conti V, Pinneri F. Fatal pulmonary embolism: When the cause is not a thrombus. Spine (Phila Pa 1976) 2012;37:E411-3.  Back to cited text no. 7
    
8.
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;18:1257-65.  Back to cited text no. 8
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9.
Sinha N, Padegal V, Satyanarayana S, Santosh HK. Pulmonary cement embolization after vertebroplasty, an uncommon presentation of pulmonary embolism: A case report and literature review. Lung India 2015;32:602-5.  Back to cited text no. 9
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10.
Lamparello NA, Jaswani V, DeSousa K, Shapiro M, Kovacs S. Percutaneous retrieval of an embolized kyphoplasty cement fragment from the pulmonary artery: A case report and literature review. J Radiol Case Rep 2016;10:40-47.  Back to cited text no. 10
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11.
Tozzi P, Abdelmoumene Y, Corno AF, Gersbach PA, Hoogewoud HM, von Segesser LK, et al. Management of pulmonary embolism during acrylic vertebroplasty. Ann Thorac Surg 2002;74:1706-8.  Back to cited text no. 11
    
12.
Rothermich MA, Buchowski JM, Bumpass DB, Patterson GA. Pulmonary cement embolization after vertebroplasty requiring pulmonary wedge resection. Clin Orthop Relat Res 2014;472:1652-7.  Back to cited text no. 12
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13.
Edelman JJ, Okiwelu N, Anvardeen K, Joshi P, Murphy B, Sanders LH, et al. Surgical pulmonary embolectomy: Experience in a series of 37 consecutive cases. Heart Lung Circ 2016;25:1240-244.  Back to cited text no. 13
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14.
Taniguchi S, Fukuda W, Fukuda I, Watanabe K, Saito Y, Nakamura M, et al. Outcome of pulmonary embolectomy for acute pulmonary thromboembolism: Analysis of 32 patients from a multicentre registry in Japan. Interact Cardiovasc Thorac Surg 2012;14:64-7.  Back to cited text no. 14
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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