Percutaneous Retrieval of an Embolized Kyphoplasty Cement Fragment

Posted By Nicole Lamparello
Percutaneous Retrieval of an Embolized Kyphoplasty Cement Fragment

A 41 year-old man presented to our institution for treatment of T7 and T8 compression fractures sustained during an epileptic seizure 3 months prior. Kyphoplasty under general anesthesia was complicated by polymethylmethacrylate cement extravasation into a paraspinal vein (Fig. 1). In real time, the tubular-shaped piece of cement was observed to migrate into the azygous vein and subsequently into the right atrium. Immediately upon extubation the patient developed hypoxia, tachypnea, and cough on deep inspiration. Chest CT confirmed the presence of a hyperdense foreign body in the right upper lobe pulmonary artery without evidence of a peripheral perfusion defect (Fig. 2A, 2B). Treatment options were discussed with the patient, who was a less than ideal candidate for long-term anticoagulation therapy given recent kyphoplasty and history of epilepsy. Open surgical embolectomy was not favored given high operative hazard and technical difficulty. Decision was made to attempt percutaneous retrieval by Interventional Radiology to avoid long-term anticoagulation and prevent long-term consequences of an indwelling thrombogenic foreign body. The right common femoral vein was cannulated with a 6F introducer sheath and the right main pulmonary artery was catheterized using a 6F pigtail catheter. The tip of an 8F 80cm sheath was then positioned in the proximal right pulmonary artery. The right upper lobe pulmonary artery was selectively catheterized using a 6F Berenstein catheter and hydrophilic guidewire. Selective angiography confirmed an 8 x 11mm filling defect within the proximal right upper lobe pulmonary artery (Fig. 3A). The foreign body was captured using a 20mm loop snare introduced through the 6F Berenstein catheter and pulled against the sheath tip (Fig. 3B). Under continuous fluoroscopic observation, the snare, catheter, and sheath were simultaneously withdrawn from the pulmonary artery, through the triscupid valve apparatus, and pulled distally through the femoral vein access (Fig. 3C). Gross specimen revealed a 1.3cm piece of polymethylmethacrylate (Fig. 3D). Shortly after intervention, the patient’s cough resolved and oxygen saturation normalized. Follow-up chest radiograph showed no residual radiopaque foreign body within the right upper lobe. He was discharged in stable condition the following day without anticoagulation therapy. Cement leakage, in particular venous embolization of cement fragments into the cardiopulmonary circulation, is a known potential complication following percutaneous kyphoplasty and vertebroplasty. While some patients with pulmonary cement embolism (PCE) are asymptomatic and likely go undiagnosed, others experience respiratory distress and hemodynamic compromise requiring surgical and medical intervention. The optimal management for PCE must be tailored to fit each individual patient, dependent upon the acuity of the clinical presentation, coexisting patient comorbidities and the risks of sys

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