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J Cardiothorac Surg
J Cardiothorac Surg
Journal of Cardiothoracic Surgery
1749-8090
BioMed Central London

39307888
3049
10.1186/s13019-024-03049-3
Case Report
Pulmonary embolism and intracardiac foreign bodies caused by bone cement leakage: a case report and literature review
Zhao Zihan 12
Wang Ranran 12
Gao Lihua 12
Zhang Meijing zmj0904@163.com

123
1 https://ror.org/01yb3sb52 grid.464204.0 0000 0004 1757 5847 Cardiac Department, Aerospace Center Hospital, Beijing, China
2 https://ror.org/02v51f717 grid.11135.37 0000 0001 2256 9319 Peking University Aerospace School of Clinical Medicine, Beijing, China
3 grid.11135.37 0000 0001 2256 9319 Cardiac Department, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, 15 Yuquan Road, Haidian District, Beijing, 100049 China
23 9 2024
23 9 2024
2024
19 54413 6 2024
9 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Percutaneous vertebroplasty (PVP) is a surgical procedure that involves injecting polymethylmethacrylate (PMMA) bone cement into the diseased vertebrae to rapidly relieve pain and strengthen the vertebrae. We reported a 73-year-old patient who underwent percutaneous vertebroplasty (PVP) surgery for thoracolumbar vertebral compression fracture. After the surgery, the patient experienced symptoms such as chest tightness and dyspnea. Further examination revealed multiple high-density foreign bodies in the blood vessels/heart and concomitant multi-organ dysfunction. It was considered that the multi-organ embolism was caused by bone cement leakage. The patient improved after undergoing surgical treatment and anticoagulant therapy.

Keywords

Percutaneous vertebroplasty
Bone cement
Pulmonary embolism
Cardiac foreign body
Multiple organ embolism
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Percutaneous vertebroplasty (PVP) is a surgical procedure that involves injecting polymethylmethacrylate (PMMA) bone cement into the diseased vertebrae to rapidly relieve pain and strengthen the vertebrae. Complications of PVP include pain, infection, bleeding, and damage to nerve roots or adjacent organs, with the main risk often related to cement leakage [1]. This case report presents a case of multi-organ embolism after PVP surgery and describes the diagnosis and treatment process, providing reference for the diagnosis and treatment of similar patients.

Case description

A 73-year-old female was admitted to the hospital due to “chest tightness and shortness of breath for 5 days.” The patient had intermittent chest tightness and shortness of breath without obvious cause 5 days ago, accompanied by palpitations, without chest pain, radiating pain, dizziness, syncope, nausea, or vomiting. Symptoms could be relieved after resting for a few minutes. Complete laboratory tests at an outside hospital showed elevated inflammatory markers, and symptomatic anti-infective treatment was administered. However, the symptoms recurred, and upon emergency department admission to our hospital, laboratory tests showed elevated inflammatory markers, significantly elevated D-dimer and liver enzymes, and echocardiography revealed a large amount of pericardial effusion. The patient was admitted to our department for further diagnosis and treatment. Past surgical history includes appendectomy 40 years ago, PVP for compression fracture of the thoracic vertebra 1 year ago, and a repeat procedure for lumbar vertebra 10 days ago. The patient was diagnosed with pulmonary tuberculosis 50 years ago, which improved with medication. There is no history of hypertension, diabetes, renal insufficiency, hyperlipidemia, other surgeries, blood transfusions, trauma, smoking, alcohol consumption, or family hereditary diseases. On admission, vital signs were as follows: temperature 36.5 °C, heart rate 121 beats/minute, respiratory rate 20 breaths/minute, blood pressure 130/82 mmHg, and no abnormal findings on examination of the heart, lungs, and abdomen. Laboratory tests showed: white blood cell count 13.29 × 10^9/L, neutrophil percentage 78%, hemoglobin 107 g/L, platelets 160 × 10^9/L, potassium 4.42mmol/L, sodium 131.4mmol/L, urea 15.1mmol/L, creatinine 91.2 µmol/L, ALT 517.6U/L, AST 646U/L, amylase 209.8U/L, lipase 71.7U/L, D-dimer 4306 µg/L, FDP 35.86 mg/L, BNP 72.9pg/ml, TnI 0.03ng/ml, CK-MB 0.63ng/ml. Blood gas analysis did not show hypoxemia. Urine and stool routine tests and thyroid function tests were generally normal. PPD test and tuberculosis antibody were negative. ECG did not show any abnormalities. Echocardiography revealed a fluid collection in the pericardial sac, with approximate depths of 10 mm in the posterior wall of the left ventricle, 11 mm in the lateral wall of the left ventricle, 14 mm in the inferior wall of the left ventricle, 10 mm in the anterior wall of the right ventricle, and 15 mm in the free wall of the right ventricle. Lower extremity venous Doppler ultrasound did not show any abnormalities. Head CT showed lacunar infarction. The CT scan of the chest showed bilateral old changes in the lungs, bilateral pleural effusion, pericardial effusion, coronary artery calcification, high-density shadow in the right ventricle (Fig. 1), and high-density shadows in the bilateral pulmonary arteries (Fig. 2). The abdominal CT scan showed slight thickening of the left adrenal gland, duodenal diverticulum, compression fracture of the 12th thoracic and 1st lumbar vertebrae with postoperative changes, and a tubular shadow in the inferior vena cava and on the right side of the spine (Fig. 3).

Fig. 1 High density shadows visible in the right ventricle

Fig. 2 High density shadows of bilateral pulmonary arteries visible in the mediastinal window of chest CT

Fig. 3 Tubular shadows in the inferior vena cava and on the right side of the spine

Diagnosis and treatment process

The patient was admitted to the hospital due to chest tightness and dyspnea accompanied by a large amount of pericardial effusion. Considering the emergency laboratory results of “pericardial effusion, liver dysfunction, elevated D-dimer,” combined with the patient’s history of previous tuberculosis, tuberculosis pericardial effusion was initially considered. However, the completed PPD test and tuberculosis antibody detection were both negative. Further check in chest-abdomen-pelvis CT examination suggested dense shadows in the right ventricle, high-density shadows in the bilateral pulmonary arteries, compression fractures of the 12th thoracic and 1st lumbar vertebrae with postoperative changes, intravascular and tube-shaped shadows on the right side of the spine. Based on the recent history of the patient undergoing percutaneous vertebral body augmentation, reviewing the pre-hospital imaging data (Fig. 4), it was clear that the symptoms of the patient were caused by multiple embolisms (inferior vena cava embolism, pulmonary embolism, hepatic embolism, pancreatic embolism, and foreign body in the heart) resulting from the fracture of bone cement after the percutaneous vertebral body augmentation procedure. Subsequent thrombosis occurred. After treatment with anticoagulants, hepatoprotective agents, diuretics, and anti-infective therapy, the above abnormal indicators improved compared to before. The patient underwent the removal of the foreign body from the heart and cardiac repair under cardiopulmonary bypass, and postoperatively, the patient’s vital signs were stable, and the condition improved. Follow-up examinations showed no abnormalities in various indicators.

Fig. 4 A Abdominal CT sagittal map after bone cement surgery; B Follow up abdominal CT sagittal map after admission

Discussion

The PVP procedure involves injecting PMMA bone cement into the diseased vertebra to rapidly relieve pain and strengthen the vertebra. It is commonly used to treat osteoporotic vertebral compression fractures, vertebral metastases, multiple myeloma and vertebral hemangiomas [1]. With advancements in technology, new techniques such as percutaneous kyphoplasty (PKP) [2] and bone cement augmented pedicle screw fixation (BCAPSF) [3] have been developed to achieve better therapeutic effects and lower postoperative complications. Complications associated with PVP and related procedures primarily include pain, infection, bleeding, and damage to nerve roots or adjacent organs. The main risks are often related to cement leakage. PMMA, being a foreign body, is not absorbed by the body and is considered to have potential thrombogenicity due to its irregular shape and porous surface. While in most patients, the cement particles are small and dispersed, leading to clinically inconspicuous symptoms in case of embolism, there have been reported cases of fatal complications such as pulmonary embolism, paradoxical cerebral embolism, right ventricular perforation, renal artery embolism, and acute respiratory distress syndrome [4].

Pulmonary Cement Embolism (PCE) is a relatively rare postoperative complication of percutaneous vertebroplasty (PVP), mainly associated with cement leakage. The vast majority of cases do not present with obvious clinical symptoms. However, some patients may exhibit non-life-threatening clinical symptoms such as chest pain, dyspnea, tachypnea, tachycardia, cough, hemoptysis, palpitations, and dizziness. These symptoms may be transient or persistent. The most severe manifestation of PCE involves embolism-induced hemodynamic abnormalities, leading to symptoms such as pulmonary hypertension, heart failure, and potentially progressing to respiratory or cardiac arrest, shock, or even death. The pathway for bone cement pulmonary embolism leakage involves the cement initially entering the paravertebral venous plexus, then entering the vertebral venous system, and ultimately reaching the pulmonary artery and its branches [5]. Common risk factors include the location of the fracture, the number of segments (more common in thoracic vertebrae [6]), the type of fracture or bone destruction (more common in tumor-related fractures [7]), the amount of bone cement, the mixing ratio, viscosity, state of the bone cement [8] and the surgical approach [9].Some studies [6, 10] have confirmed that the number of affected vertebrae, the location of the lesion, the puncture pathway, the duration of surgery, and the amount of PMMA injected are independent risk factors for PCE. If cement leaks into the paravertebral venous plexus of the thoracic vertebrae, the incidence of PCE is significantly higher. The most commonly used imaging examinations are chest X-ray (1-6.8%) or CT (2.1-26%). The imaging features show tubular or branching high-density opacities corresponding to the distribution of arteries [11], and cement emboli can often be found in the paravertebral veins and the azygos venous system. In recent years, the selection of some emerging surgical methods has reduced the incidence of complications for preventing cement leakage, such as low-dose cement injection [12], the use of high-viscosity bone cement [8], the application of other materials (special screws [3], etc.), the selection of different surgical approaches (midline approach, Wiltse approach, unilateral approach [13]), and the use of some special techniques (pre-filling technique [14]). Due to the unpredictable nature of this complication, it is recommended to conduct postoperative chest X-ray examinations to exclude this diagnosis, even in asymptomatic patients. Currently, there are no standard guidelines for the treatment of PCE patients. Treatment plans often depend on the severity of symptoms and the location of the cement embolus. For patients with mild or no symptoms, observation or continuous anticoagulant therapy for 3–6 months may be considered. For patients with severe symptoms or hemodynamically unstable conditions, most studies still recommend surgical removal as the treatment of choice [15].

The intracardiac cement embolism (ICE) is a relatively rare but potentially life-threatening complication, with a reported low incidence rate (3.9%) in a single-center retrospective analysis, most of which coexist with PCE, and ICE-related symptoms and complications (0.3%) are even rarer [16]. After bone cement enters the ventricle, it can lead to tricuspid regurgitation [17], heart failure, cardiac perforation, and can further migrate to the pulmonary artery, causing symptoms such as chest pain, dyspnea, and shock, posing a life-threatening risk. Intracardiac bone cement embolism often occurs when the venous system cement embolism ruptures and circulates to the heart, and due to the presence of broken ends, there is a relatively high risk of perforation or valve dysfunction. Currently, most studies [18, 19] recommend intervention or open surgery to remove the cement for treatment, but a small number of studies [20] also suggest that anticoagulant therapy may be considered for asymptomatic intracardiac embolism to promote encapsulation and reduce potential thrombus formation. Ziad et al. [21] found through a literature review that at present, intracardiac cement embolism is a rare complication after vertebroplasty or kyphoplasty. Most cases were diagnosed during surgery or in a short time after surgery, and in most cases, open-heart surgery was chosen to remove the embolism, while a few chose to use catheter technology. The safety and superiority of conservative treatment remain unclear.

In this case, the patient presented with pericardial effusion as the initial symptom. Based on the patient’s history of previous surgeries and laboratory test results, it was ultimately considered that the patient had bone cement leakage into the heart and lungs after PVP, leading to secondary liver dysfunction, thrombosis, and cardiac perforation. The patient was treated conservatively with medication, followed by removal of the foreign body from the heart and cardiac repair surgery. The patient had a good prognosis after the surgery. The purpose of reporting this case of multi-organ dysfunction after PVP is to raise awareness among clinical doctors about the potential complications of PVP, in order to achieve early diagnosis, treatment, and prevention of serious complications. It also calls for the development of new technologies or methods to reduce the occurrence of related surgical complications, or to treat complications through non-invasive means.

Author contributions

Zihan Zhao-Conceptualization, data curation, writing (original draft). Ranran Wang- Formal analysis, methodology, validation. Lihua Gao- Formal analysis, methodology, validation. Meijing Zhang- Conceptualization, methodology, writing (review & editing).

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Written informed consent was obtained from the participant/patient(s) for the publication of this case report.

Consent for publication

All authors agree to the publication of the article.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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