Downloaded from http://heart.bmj.com/ on March 14, 2015 - Published by group.bmj.com
Images in cardiology
Massive cement pulmonary embolism during percutaneous vertebroplasty A 71-year-old woman was admitted to hospital after a car crash and diagnosed with L1 vertebral body fracture. A percutaneous transpedicular lumbar fixation using polymethylmethacrylate (PMMA) cement was decided. During the procedure, a massive PMMA cement leakage into the paravertebral venous system was observed. Hypotension, acute respiratory distress and refractory hypoxaemia were rapidly manifested. A cement pulmonary embolism was suspected and an unenhanced CT performed. A large collection of PMMA fragments were distinguished in the right pulmonary artery (RPA) and lobar branches (figure 1A). A huge PMMA piece was seen inside the RV (figure 1B) and identified on chest radiography (figure 1C). Because of the critical condition of the patient and the size of the cement pieces, surgical management was decided. During anaesthesia induction, hypotension and ventricular tachycardia appeared. Cardiopulmonary bypass was immediately established. Through the right atriotomy, the RV was explored without findings. Afterwards, an RPA arteriotomy revealed elongated PMMA fragments in the right pulmonary branches (figure 1D). A main pulmonary trunk arteriotomy showed a huge PMMA piece entrapped in the main pulmonary bifurcation (figure 1E). A large collection of cement fragments were successfully removed (figure 1F). The larger piece resembled the big
one detected inside the RV on CT and chest radiography, probably embolised during induction of anaesthesia and responsible for the final acute hemodynamic instability. Postoperatively, the patient recovered uneventfully. PMMA cement pulmonary artery embolism is a rare complication after percutaneous vertebroplasty. Frequently underreported, clinical manifestations are variable, from asymptomatic to respiratory distress or death. Treatment is controversial. The current trend consists of conservative management. Pulmonary embolectomy is exceptional and usually associated with high mortality. María Elena Arnáiz-García, María José Dalmau-Sorlí, Jose María González-Santos Cardiac Surgery Department, University Hospital of Salamanca, Salamanca, Spain Correspondence to Dr María Elena Arnáiz-García, Cardiac Surgery Department, University Hospital of Salamanca, Paseo de San Vicente 58-182, Salamanca 37007, Spain; [email protected] Contributors All authors have participated on writing, designing of manuscript, analysis, photo editing and critical review. All authors have participated in the work and have reviewed and agreed with the content of the article. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed. To cite Arnáiz-García ME, Dalmau-Sorlí MJ, González-Santos JM. Heart 2014;100:600. Received 4 July 2013 Accepted 12 September 2013 Published Online First 22 October 2013 Heart 2014;100:600. doi:10.1136/heartjnl-2013-304583
Figure 1 (A) Unenhanced CT shows several hyperdense intraluminal opacities into the distal right pulmonary artery (RPA) and lobar branches (arrow). (B) CT scan reveals a hyperdense material inside the RV consistent with cement embolism. (C) Chest radiograph confirming presence of a big cement piece inside the RV. (D) Extraction of filamentous fragments of polymethylmethacrylate (PMMA) from the RPA. (E) Removal of the big PMMA cement piece through the main pulmonary trunk arteriotomy, consistent with the big piece observed preoperatively inside the RV on CT scan and chest radiograph. (F) All PMMA fragments removed during surgery.
600
Arnáiz-García ME, et al. Heart April 2014 Vol 100 No 7
Downloaded from http://heart.bmj.com/ on March 14, 2015 - Published by group.bmj.com
Massive cement pulmonary embolism during percutaneous vertebroplasty María Elena Arnáiz-García, María José Dalmau-Sorlí and Jose María González-Santos Heart 2014 100: 600 originally published online October 22, 2013
doi: 10.1136/heartjnl-2013-304583 Updated information and services can be found at: http://heart.bmj.com/content/100/7/600
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To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Images in cardiology
Massive cement pulmonary embolism during percutaneous vertebroplasty A 71-year-old woman was admitted to hospital after a car crash and diagnosed with L1 vertebral body fracture. A percutaneous transpedicular lumbar fixation using polymethylmethacrylate (PMMA) cement was decided. During the procedure, a massive PMMA cement leakage into the paravertebral venous system was observed. Hypotension, acute respiratory distress and refractory hypoxaemia were rapidly manifested. A cement pulmonary embolism was suspected and an unenhanced CT performed. A large collection of PMMA fragments were distinguished in the right pulmonary artery (RPA) and lobar branches (figure 1A). A huge PMMA piece was seen inside the RV (figure 1B) and identified on chest radiography (figure 1C). Because of the critical condition of the patient and the size of the cement pieces, surgical management was decided. During anaesthesia induction, hypotension and ventricular tachycardia appeared. Cardiopulmonary bypass was immediately established. Through the right atriotomy, the RV was explored without findings. Afterwards, an RPA arteriotomy revealed elongated PMMA fragments in the right pulmonary branches (figure 1D). A main pulmonary trunk arteriotomy showed a huge PMMA piece entrapped in the main pulmonary bifurcation (figure 1E). A large collection of cement fragments were successfully removed (figure 1F). The larger piece resembled the big
one detected inside the RV on CT and chest radiography, probably embolised during induction of anaesthesia and responsible for the final acute hemodynamic instability. Postoperatively, the patient recovered uneventfully. PMMA cement pulmonary artery embolism is a rare complication after percutaneous vertebroplasty. Frequently underreported, clinical manifestations are variable, from asymptomatic to respiratory distress or death. Treatment is controversial. The current trend consists of conservative management. Pulmonary embolectomy is exceptional and usually associated with high mortality. María Elena Arnáiz-García, María José Dalmau-Sorlí, Jose María González-Santos Cardiac Surgery Department, University Hospital of Salamanca, Salamanca, Spain Correspondence to Dr María Elena Arnáiz-García, Cardiac Surgery Department, University Hospital of Salamanca, Paseo de San Vicente 58-182, Salamanca 37007, Spain; [email protected] Contributors All authors have participated on writing, designing of manuscript, analysis, photo editing and critical review. All authors have participated in the work and have reviewed and agreed with the content of the article. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed. To cite Arnáiz-García ME, Dalmau-Sorlí MJ, González-Santos JM. Heart 2014;100:600. Received 4 July 2013 Accepted 12 September 2013 Published Online First 22 October 2013 Heart 2014;100:600. doi:10.1136/heartjnl-2013-304583
Figure 1 (A) Unenhanced CT shows several hyperdense intraluminal opacities into the distal right pulmonary artery (RPA) and lobar branches (arrow). (B) CT scan reveals a hyperdense material inside the RV consistent with cement embolism. (C) Chest radiograph confirming presence of a big cement piece inside the RV. (D) Extraction of filamentous fragments of polymethylmethacrylate (PMMA) from the RPA. (E) Removal of the big PMMA cement piece through the main pulmonary trunk arteriotomy, consistent with the big piece observed preoperatively inside the RV on CT scan and chest radiograph. (F) All PMMA fragments removed during surgery.
600
Arnáiz-García ME, et al. Heart April 2014 Vol 100 No 7
Downloaded from http://heart.bmj.com/ on March 14, 2015 - Published by group.bmj.com
Massive cement pulmonary embolism during percutaneous vertebroplasty María Elena Arnáiz-García, María José Dalmau-Sorlí and Jose María González-Santos Heart 2014 100: 600 originally published online October 22, 2013
doi: 10.1136/heartjnl-2013-304583 Updated information and services can be found at: http://heart.bmj.com/content/100/7/600
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
