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01-02-2019 | Interventional

Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management

Authors: Sarah Fadili Hassani, Evelyne Cormier, Eimad Shotar, Mehdi Drir, Jean-Philippe Spano, Laetitia Morardet, Jean-Philippe Collet, Jacques Chiras, Frédéric Clarençon

Published in: European Radiology | Issue 2/2019

Abstract

Objective

To evaluate the incidence and risk factors for ICE during a PV.

Materials and methods

Single-center retrospective analysis of 1512 consecutive patients who underwent 1854 PV procedures for osteoporotic (34 %), malignant (39.9 %) or other cause (26.1 %) of vertebral compression fractures (VCFs)/spine tumor lesions. Only thoracic or lumbar PVs were included. PVs were performed with polymethylmethacrylate (PMMA) low-viscosity bone cement under fluoroscopic guidance. Chest imaging (X-ray or CT) was performed the same day after PV in patients with high clinical suspicion of ICE. All post-procedural chest-imaging examinations were reviewed, and all ICEs were agreed upon in consensus by two radiologists.

Results

ICEs were detected in 72 patients (92 cement embolisms). In 86.1 % of the cases, concomitant pulmonary artery cement leakage was detected. Symptomatic ICEs were observed in six cases (8.3% of all ICEs; 0.32% of all PV procedures). No ICE led to death or permanent sequelae. Multiple levels treated during the same PV session were associated with a higher ICE rate [OR: 3.59, 95% CI: (1.98-6.51); p < 0.001]; the use of flat panel technology with a lower ICE occurrence [OR: 0.51, 95% CI: (0.32-0.83); p = 0.007].

Conclusion

Intracardiac cement embolism after PV has a low incidence (3.9 % in our study). Symptomatic complications related to ICE are rare (0.3%); none was responsible for clinical sequelae in our series.

Key Points

• The incidence of intracardiac cement embolism (ICE) during PVP is low (3.9%).

• Having a high number of treated vertebrae during the same session is a significant risk factor for ICE.

• Symptomatic intracardiac cement embolisms have a low incidence (8.3% of patients with ICE).

Calmels V, Vallée J-N, Rose M, Chiras J (2007) Osteoblastic and mixed spinal metastases: evaluation of the analgesic efficacy of percutaneous vertebroplasty. AJNR Am J Neuroradiol 28:570–574PubMedPubMedCentral

Anselmetti GC, Marcia S, Saba L et al (2012) Percutaneous vertebroplasty: multi-centric results from EVEREST experience in large cohort of patients. Eur J Radiol 81:4083–4086. https://doi.org/10.1016/j.ejrad.2012.07.005 CrossRefPubMed

Clarençon F, Fahed R, Gabrieli J et al (2016) Safety and clinical effectiveness of percutaneous vertebroplasty in the elderly (≥80 years). Eur Radiol 26:2352–2358. https://doi.org/10.1007/s00330-015-4035-2 CrossRefPubMed

Barragán-Campos HM, Vallée J-N, Lo D et al (2006) Percutaneous vertebroplasty for spinal metastases: complications. Radiology 238:354–362. https://doi.org/10.1148/radiol.2381040841 CrossRefPubMed

Masala S, Mastrangeli R, Petrella MC et al (2009) Percutaneous vertebroplasty in 1,253 levels: results and long-term effectiveness in a single centre. Eur Radiol 19:165–171. https://doi.org/10.1007/s00330-008-1133-4 CrossRefPubMed

Mathis JM (2003) Percutaneous vertebroplasty: complication avoidance and technique optimization. AJNR Am J Neuroradiol 24:1697–1706PubMedPubMedCentral

Chen Y-J, Tan T-S, Chen W-H et al (2006) Intradural cement leakage: a devastatingly rare complication of vertebroplasty. Spine 31:E379–E382. https://doi.org/10.1097/01.brs.0000219495.57470.67 CrossRefPubMed

Gaye M, Fuentes S, Pech-Gourg G et al (2008) Spondylodiscite post-vertébroplastie. Cas clinique et revue de la littérature. Neurochirurgie 54:551–555. https://doi.org/10.1016/j.neuchi.2008.02.063 CrossRefPubMed

Laredo JD, Hamze B (2004) Complications of percutaneous vertebroplasty and their prevention. Skeletal Radiol 33. doi: https://doi.org/10.1007/s00256-004-0776-8

10.

Groen RJM, du Toit DF, Phillips FM et al (2004) Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: a reappraisal of the vertebral venous system. Spine (Phila Pa 1976) 29:1465–1471

11.

Schmidt R, Cakir B, Mattes T et al (2005) Cement leakage during vertebroplasty: an underestimated problem? Eur Spine J 14:466–473. https://doi.org/10.1007/s00586-004-0839-5 CrossRefPubMedPubMedCentral

12.

Geraci G, Lo Iacono G, Lo Nigro C, Cannizzaro F, Cajozzo M, Modica G (2013) Asymptomatic bone cement pulmonary embolism after vertebroplasty: case report and literature review. Case Rep Surg 2013, 2013:591432. https://doi.org/10.1155/2013/591432

13.

Venmans A, Klazen CAH, Lohle PNM et al (2010) Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II. AJNR Am J Neuroradiol 31:1451–1453. https://doi.org/10.3174/ajnr.A2127 CrossRefPubMedPubMedCentral

14.

Luetmer MT, Bartholmai BJ, Rad AE, Kallmes DF (2011) Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty. AJNR Am J Neuroradiol 32:654–657. https://doi.org/10.3174/ajnr.A2368 CrossRefPubMedPubMedCentral

15.

Venmans A, Lohle PNM, van Rooij WJ et al (2008) Frequency and outcome of pulmonary polymethylmethacrylate embolism during percutaneous vertebroplasty. AJNR Am J Neuroradiol 29:1983–1985. https://doi.org/10.3174/ajnr.A1269 CrossRefPubMedPubMedCentral

16.

Kim YJ, Lee JW, Park KW et al (2009) Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors. Radiology 251:250–259. https://doi.org/10.1148/radiol.2511080854 CrossRefPubMed

17.

Kim SY, Seo JB, Do K-H et al (2005) Cardiac perforation caused by acrylic cement: a rare complication of percutaneous vertebroplasty. AJR Am J Roentgenol 185:1245–1247. https://doi.org/10.2214/AJR.04.1443

18.

Schuerer S, Misfeld M, Schuler G, Mangner N (2015) Intracardiac cement embolization in a 65-year-old man four months after multilevel spine fusion. Eur Heart J 36:783. https://doi.org/10.1093/eurheartj/ehu300 CrossRefPubMed

19.

Dash A, Brinster DR (2011) Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty. Ann Thorac Surg 91:276–278. https://doi.org/10.1016/j.athoracsur.2010.06.106 CrossRefPubMed

20.

Llanos RA, Viana-Tejedor A, Abella HR, Fernandez-Avilés F (2013) Pulmonary and intracardiac cement embolism after a percutaneous vertebroplasty. Clin Res Cardiol 102:395–397. https://doi.org/10.1007/s00392-013-0542-9 CrossRefPubMed

21.

Hatzantonis C, Czyz M, Pyzik R, Boszczyk BM (2016) Intracardiac bone cement embolism as a complication of vertebroplasty: management strategy. Eur Spine J. https://doi.org/10.1007/s00586-016-4695-x

22.

Audat ZA, Alfawareh MD, Darwish FT, Alomari AA (2016) Intracardiac leakage of cement during kyphoplasty and vertebroplasty: a case report. Am J Case Rep 17:326–330CrossRefPubMedPubMedCentral

23.

Mattis T, Knox M, Mammen L (2012) Intracardiac methylmethacrylate embolism resulting in right atrial wall perforation and pericarditis following percutaneous vertebroplasty. J Vasc Interv Radiol 23:719–720. https://doi.org/10.1016/j.jvir.2011.12.027 CrossRefPubMed

24.

Shridhar P, Chen Y, Khalil R et al (2016) A review of PMMA bone cement and intra-cardiac embolism. Materials (Basel) 9:821. https://doi.org/10.3390/ma9100821

25.

Righini M, Sekoranja L, Le Gal G et al (2006) Pulmonary cement embolism after vertebroplasty. Thromb Haemost 95:388–389CrossRefPubMed

26.

Krueger A, Bliemel C, Zettl R, Ruchholtz S (2009) Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J 18:1257–1265. https://doi.org/10.1007/s00586-009-1073-y CrossRefPubMedPubMedCentral

27.

Nieuwenhuijse MJ, Van Erkel AR, Dijkstra PDS (2011) Cement leakage in percutaneous vertebroplasty for osteoporotic vertebral compression fractures: identification of risk factors. Spine J 11:839–848. https://doi.org/10.1016/j.spinee.2011.07.027 CrossRefPubMed

28.

Loeffel M, Ferguson SJ, Nolte L-P, Kowal JH (2008) Vertebroplasty: experimental characterization of polymethylmethacrylate bone cement spreading as a function of viscosity, bone porosity, and flow rate. Spine (Phila Pa 1976) 33:1352–1359. https://doi.org/10.1097/BRS.0b013e3181732aa9

29.

Bohner M, Gasser B, Baroud G, Heini P (2003) Theoretical and experimental model to describe the injection of a polymethylmethacrylate cement into a porous structure. Biomaterials 24:2721–2730CrossRefPubMed

30.

Baroud G, Crookshank M, Bohner M (2006) High-viscosity cement significantly enhances uniformity of cement filling in vertebroplasty: an experimental model and study on cement leakage. Spine (Phila Pa 1976) 31:2562–2568. https://doi.org/10.1097/01.brs.0000240695.58651.62

31.

Meng B, Qian M, Xia S-X et al (2013) Biomechanical characteristics of cement/gelatin mixture for prevention of cement leakage in vertebral augmentation. Eur Spine J 22:2249–2255. https://doi.org/10.1007/s00586-013-2886-2 CrossRefPubMedPubMedCentral

32.

Potet J, Weber-Donat G, Curis E et al (2013) Incidence of pulmonary cement embolism after real-time CT fluoroscopy-guided vertebroplasty. J Vasc Interv Radiol 24:1853–1860. https://doi.org/10.1016/j.jvir.2013.05.048

Title: Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management
Authors: Sarah Fadili Hassani
Evelyne Cormier
Eimad Shotar
Mehdi Drir
Jean-Philippe Spano
Laetitia Morardet
Jean-Philippe Collet
Jacques Chiras
Frédéric Clarençon
Publication date: 01-02-2019
Publisher: Springer Berlin Heidelberg
Published in: European Radiology / Issue 2/2019
Print ISSN: 0938-7994
Electronic ISSN: 1432-1084
DOI: https://doi.org/10.1007/s00330-018-5647-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Intracardiac cement embolism during percutaneous vertebroplasty: incidence, risk factors and clinical management

Abstract

Objective

Materials and methods

Results

Conclusion

Key Points

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Materials and methods

Results

Conclusion

Key Points

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