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Cement pulmonary embolism following vertebroplasty

Linda Albusoul, Diana Alaouie,Al Muthanna Shadid, Christopher Kassab,Rana L. Adawi Awdish

CHEST(2023)

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摘要
SESSION TITLE: Unique, Unusual, and Unsuspecting Pulmonary Emboli SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Pulmonary cement embolism (PCE) is a rare but potentially serious complication that can occur following vertebroplasty1. It occurs due to the leakage of polymethylmethacrylate (PMMA) into the valveless paravertebral venous system and then into the thoracic venous system1. Guidelines are yet to be established for the management of PCE. Here, we report a case of PCE following vertebroplasty. CASE PRESENTATION: An 81-year-old female patient with a history of chronic obstructive pulmonary disease with associated pulmonary hypertension and heart failure with preserved ejection fraction presented following a mechanical fall causing a large epidural hematoma, unstable T12 fracture and L1 compression fracture. She underwent evacuation of epidural hematoma as well as T10-L1 decompression and stabilization with cement augmentation. Her immediate post-operative course was complicated by cardiac arrest, and she achieved return of spontaneous circulation during the first cycle of cardiopulmonary resuscitation, however, she remained lethargic and was intubated for airway protection. The patient's mentation improved, and she was able to be extubated. Her course was complicated by respiratory distress. Computed tomography (CT) the chest showed a pulmonary cement embolism within the right middle lobe pulmonary artery extending into the segmental and subsegmental branches with no evidence of right heart strain and bilateral pleural effusions. Subsequently, the pulmonary embolism response team was consulted, and hypoxia was attributed to bilateral pleural effusions primarily, as pulmonary cement embolism was small with no evidence of right heart strain. Therefore, the decision was to optimize the patient's volume status. Anticoagulation was contraindicated given the recent history of epidural hematoma. Unfortunately, the patient continued to decline and suffered subsequent cardiac arrest. The patient's family elected to pursue comfort care. DISCUSSION: PCEs present with a variety of clinical manifestations from asymptomatic to dyspnea being most common (1,2). Symptoms can occur weeks or months following the procedure (3). PCE can be diagnosed with chest radiography or CT. On CT, it appears as a radiodensity of more than 1,000 Hounsfield units which distinguishes it from a thromboembolism2. Treatment options include supportive management, anticoagulation, embolectomy, or close clinical observation (2,3). Anticoagulation is indicated due to the prothrombotic nature of PMMA and is the most utilized treatment option for symptomatic patients with a recommended duration of 3 to 6 months (3). CONCLUSIONS: In our case and recent history of epidural hematoma, the risk of anticoagulation outweighed the benefit, and the decision was for conservative management. It is important to remain vigilant about the potential risk of PCE following vertebroplasty for prompt recognition. There is no clear consensus on management of PCEs and therefore management should be guided by the individual patient's clinical condition. REFERENCE #1: 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 Nov-Dec;32(6):602-5. 10.4103/0970-2113.168119. REFERENCE #2: Alex R. Waler, Kyle J. Sanchez, Amay A. Parikh, Okorie N. Okorie, "A Case of Pulmonary Cement Embolism Managed through Symptomatic Treatment", Case Reports in Critical Care, vol. 2020, Article ID 2425973, 4 pages, 2020. 10.1155/2020/2425973 REFERENCE #3: Jang EC, Ryu W, Woo SY, Kim JS, Lee KH, Ryu JS, Kwak SM, Lee HL, Nam HS. Diagnosis of pulmonary cement embolism using only the bone window setting on computed tomography: a case report. J Int Med Res. 2020 May;48(5). 10.1177/0300060520926005. DISCLOSURES: No relevant relationships by Rana Adawi Awdish No relevant relationships by Diana Alaouie No relevant relationships by Linda Albusoul No relevant relationships by Christopher Kassab No relevant relationships by Al Muthanna Shadid
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关键词
cement pulmonary embolism,pulmonary embolism,vertebroplasty
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