Complications after percutaneous vertebroplasty : cardiac rupture and pulmonary embolism

Complications after percutaneous vertebroplasty : cardiac rupture and pulmonary embolism | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 9 January 2025 V1 Latest version Share on Complications after percutaneous vertebroplasty : cardiac rupture and pulmonary embolism Authors : Qingqing Shi , Zhidong Zhang , and Xin-Qiao Tian [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.173639541.12604716/v1 160 views 75 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Bone cement embolization is a known complication after percutaneous vertebroplasty ( PVP ). It is crucial to identify it in time. We present a case of an elderly man who was initially diagnosed with acute coronary syndrome due to chest pain and chest tightness. After echocardiography and chest computed tomography（CT）examination, we realized that the patient had bone cement embolism. Complications after percutaneous vertebroplasty : cardiac rupture and pulmonary embolism Qingqing Shi, Zhidong Zhang,and Xinqiao Tian Department of Ultrasound,CentralChina Fuwai Hospital of Zhengzhou University,Zhengzhou 450000,China and Department of Major Vascular Surgery,CentralChina Fuwai Hospital of Zhengzhou University,Zhengzhou 450000,China Corresponding authors.Tel:+86 13838067936,Email: [email protected] CONFLICT OF INTEREST The authors have no conflicts of interest to declare. Abstract Bone cement embolization is a known complication after percutaneous vertebroplasty ( PVP ). It is crucial to identify it in time. We present a case of an elderly man who was initially diagnosed with acute coronary syndrome due to chest pain and chest tightness. After echocardiography and chest computed tomography（CT）examination, we realized that the patient had bone cement embolism. KEYWORDS percutaneous vertebroplasty,cardiac rupture,pulmonary embolism,echocardiography Case description A 75-year-old male came to our hospital for chest tightness and chest pain for 5 days and aggravation for 1 day. One day ago, the above symptoms aggravated at night, accompanied by dyspnea. Previous history of hypertension, history of prostate surgery and 50 days ago after traumatic lumbar fracture surgery. Initial diagnosis : coronary atherosclerotic heart disease, acute coronary syndrome, hypertension.Laboratory tests showed elevated inflammatory markers and liver enzymes, and a significant increase in D-dimer. The electrocardiogram did not show special abnormalities. Echocardiography showed a large amount of pericardial effusion (Figure 1A-B), and a strip of strong echoes about 3.5 mm wide was seen in the right atrium and ventricle (Figure 1C).The liquid dark area can be detected in the pericardial cavity. The depth of the anterior wall of the right ventricle is about 17 mm, the depth of the posterior wall of the left ventricle is about 22 mm, the depth of the left ventricular apex is about 24.3 mm, the depth of the left ventricular lateral wall is about 25.4 mm, and the depth of the right ventricular lateral wall is about 18.8 mm.CT showed a high-density shadow of the superior vena cava-right heart cavity, inferior vena cava and pulmonary artery tract (Figures 2A-C) localized to the right ventricular wall, and a pericardial effusion. Ultrasound-guided pericardial puncture extracted a large amount of bloody fluid. Considering the critical and complicated condition,the surgeon decided to operate immediately.During the operation, it was found that there were extensive adhesions in the pericardial cavity and a large number of old thrombosis .A large number of cord-like hard objects were seen in the atrium, superior vena cava, azygos vein, left and right pulmonary artery.Some of these pierced into the atrium, atrial septum and pulmonary artery wall.Therefore, pulmonary endarterectomy + cardiac incision foreign body removal + vena cava patch repair + pulmonary artery tissue patch repair was performed. The bone cement emboli were removed ( Figures 3A-C ). No residual foreign body was found in the heart cavity by intraoperative esophageal ultrasonography. The vital signs of the patients were stable after operation. FIGURE 1 A,The liquid dark area of right ventricular lateral wall was about 18.8 mm deep by transthoracic echocardiography.B,The long axis view of the left ventricle showed that the liquid dark area of the left ventricular posterior wall was about 22 mm deep.C,There is a cord-like strong echo in the right heart of apical four-chamber view. FIGURE 2 A,CT showed postoperative changes in L3 vertebral bone cement treatment.B,There was high density shadow in the running area of double pulmonary artery.C,High density shadows were observed in the right heart cavity along with pericardial effusion. FIGURE 3 A, Bone cement emboli in the right heart were removed by surgery.B and C,Multiple bone cement emboli were found in the left and right pulmonary arteries. Discussion PVP is a minimally invasive technique that strengthens the vertebral body by injecting bone cement ( polymethylmethacrylate) into the diseased vertebral body. 1 Complications caused by surgery included mild, moderate and severe. Mild mainly includes temporary pain and transient hypotension caused by inflammatory reaction ; moderate included infection and bone cement infiltration into intervertebral foramen and epidural space ; finally, bone cement leakage into the paravertebral venous system, leading to pulmonary embolism, cardiac rupture, cerebral embolism, and even death. 2 There were also cases of postoperative inferior vena cava and bilateral iliac vein bone cement embolization reported. 3 In Sarah Fadili Hassani’s study, the incidence of intracardiac cement embolism was 3.9%, and that of pulmonary cement embolism was 24%.And most cases were asymptomatic. 4 All symptomatic complications in patients were associated with intracardiac cement embolism in the pulmonary artery. Risk factors are mainly related to the number, location of the vertebral bodies involved, and the method of puncture for injecting bone cement. 5 Bone cement that leaks into the blood vessels migrates through the paravertebral venous system to the right heart cavity or pulmonary vascular system. 6 During this process, bone cement can damage the myocardium and blood vessel walls due to the beating of the heart and the shock of the blood.There are also case reports of cement emboli entering the ventricular cavity damaging the tricuspid valve structure, leading to severe tricuspid regurgitation. 7 Usually asymptomatic patients can be treated conservatively, the preferred treatment is the use of low molecular weight heparin and warfarin for anticoagulation. 8 Symptomatic pulmonary embolism and intracardiac embolism as well as cardiac perforation rupture require surgical intervention. In this case,the patient had obvious symptoms, chest tightness, chest pain and dyspnea when he came to the hospital. Combined with the patient ’s history of traumatic lumbar fracture after percutaneous vertebroplasty 50 days ago, laboratory examination and imaging data, preoperative diagnosis of pulmonary embolism, traumatic heart rupture, a large number of pericardial effusion.The patient ’s prognosis is good after surgery.Because we found and treated the patient in time. Conclusion Echocardiography can observe pericardial effusion, accurately locate intracardiac foreign bodies, evaluate the size of foreign bodies, and comprehensively evaluate the systolic and diastolic function of the heart. It is a convenient, effective and non-invasive examination method. By understanding the complications and hazards of percutaneous vertebroplasty, we should be more cautious in clinical work. Echocardiography can be performed after PVP to exclude vascular leakage of bone cement or early diagnosis and treatment，so as to help patients relieve pain in time. 1. Gao Q, Li Q, Wang L, et al. Percutaneous vertebroplasty versus percutaneous kyphoplasty for osteoporotic vertebral compression fractures: an umbrella review protocol of systematic reviews and meta-analyses. BMJ Open . Feb 20 2024;14(2):e075225. 2. Al-Nakshabandi NA. Percutaneous vertebroplasty complications. Ann Saudi Med . May-Jun 2011;31(3):294-7. 3. Hu Y, Wang Y, Yu Z, Li X. Cement-associated thrombotic embolism in the inferior vena cava and bilateral iliac veins after percutaneous vertebroplasty: a case report. J Int Med Res . Sep 2021;49(9):3000605211046115. 4. Fadili Hassani S, Cormier E, Shotar E, et al. Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management. Eur Radiol . Feb 2019;29(2):663-673. 5. Wang L, Lu M, Zhang X, et al. Risk factors for pulmonary cement embolism after percutaneous vertebroplasty and radiofrequency ablation for spinal metastases. Front Oncol . 2023;13:1129658. 6. Ignacio JMF, Ignacio KHD. Pulmonary Embolism from Cement Augmentation of the Vertebral Body. Asian Spine J . Apr 2018;12(2):380-387.7. Duijvelshoff R, Anthonissen NFM, Morshuis WJ, Van Garsse L. Intracardiac cement embolism resulting in tricuspid regurgitation. Eur J Cardiothorac Surg . Feb 1 2019;55(2):366-368. 8. Hatzantonis C, Czyz M, Pyzik R, Boszczyk BM. Intracardiac bone cement embolism as a complication of vertebroplasty: management strategy. Eur Spine J . Dec 2017;26(12):3199-3205. Information & Authors Information Version history V1 Version 1 09 January 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords cardiac rupture echocardiography percutaneous vertebroplasty pulmonary embolism Authors Affiliations Qingqing Shi Central China Fuwai Hospital of Zhengzhou University View all articles by this author Zhidong Zhang Central China Fuwai Hospital of Zhengzhou University View all articles by this author Xin-Qiao Tian [email protected] Central China Fuwai Hospital of Zhengzhou University View all articles by this author Metrics & Citations Metrics Article Usage 160 views 75 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Qingqing Shi, Zhidong Zhang, Xin-Qiao Tian. Complications after percutaneous vertebroplasty : cardiac rupture and pulmonary embolism. Authorea . 09 January 2025. DOI: https://doi.org/10.22541/au.173639541.12604716/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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