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Successful thrombolysis, angioplasty, and stenting of delayed thrombosis in the vena cava following percutaneous vertebroplasty with polymethylmethacrylate cement

2012; Elsevier BV; Volume: 56; Issue: 4 Linguagem: Inglês

10.1016/j.jvs.2012.02.039

1097-6809

Suh Min Kim, Seung‐Kee Min, Hwan Jun Jae, Sangil Min, Jongwon Ha, Sang Joon Kim,

Spine and Intervertebral Disc Pathology

Percutaneous vertebroplasty is a widely used treatment for vertebral compression fracture. It is relatively safe, but it can be complicated by pulmonary or cerebral embolism caused by the cement injected during the procedure. Here, we present a case of a 69-year-old male with extensive deep vein thrombosis from the inferior vena cava to the right iliac and left femoral veins, which occurred 10 months after vertebroplasty. He was treated successfully by catheter-directed thrombolysis, angioplasty, and stenting. To the best of our knowledge, this is the first report of the successful treatment of delayed thrombosis caused by migrated cement inside the inferior vena cava. Percutaneous vertebroplasty is a widely used treatment for vertebral compression fracture. It is relatively safe, but it can be complicated by pulmonary or cerebral embolism caused by the cement injected during the procedure. Here, we present a case of a 69-year-old male with extensive deep vein thrombosis from the inferior vena cava to the right iliac and left femoral veins, which occurred 10 months after vertebroplasty. He was treated successfully by catheter-directed thrombolysis, angioplasty, and stenting. To the best of our knowledge, this is the first report of the successful treatment of delayed thrombosis caused by migrated cement inside the inferior vena cava. Percutaneous vertebroplasty using polymethylmethacrylate cement is widely used for the treatment of osteoporotic vertebral fractures and painful metastases to the spine.1Kim Y.J. Lee J.W. Park K.W. Yeom J.S. Jeong H.S. Park J.M. et al.Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors.Radiology. 2009; 251: 250-259Crossref PubMed Scopus (171) Google Scholar Although it is relatively safe, cement leakage into the spinal canal or paravertebral vein may occur. Cement leakage can lead to spinal cord compression or pulmonary embolism. Pulmonary embolism caused by cement leakage is a frequent complication with an incidence of 3.5% to 23%.2Krueger A. Bliemel C. Zettl R. Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.Eur Spine J. 2009; 18: 1257-1265Crossref PubMed Scopus (219) Google Scholar, 3Choe D.H. Marom E.M. Ahrar K. Truong M.T. Madewell J.E. Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty.Am J Radiol. 2004; 183: 1097-1102Google Scholar, 4Duran C. Sirvanci M. Aydoğan M. Ozturk E. Ozturk C. Akman C. Pulmonary cement embolism: a complication of percutaneous vertebroplasty.Acta Radiol. 2007; 48: 854-859Crossref PubMed Scopus (83) Google Scholar, 5Anselmetti G.C. Corgnier A. Debernardi F. Regge D. Treatment of painful compression vertebral fractures with vertebroplasty: results and complications.Radiol Med. 2005; 110: 262-272PubMed Google Scholar Most patients are asymptomatic. However, there have been several reports of symptomatic central embolism or inferior vena cava (IVC) embolism which required open heart surgery or endovascular retrieval.2Krueger A. Bliemel C. Zettl R. Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.Eur Spine J. 2009; 18: 1257-1265Crossref PubMed Scopus (219) Google Scholar, 6Dash A. Brinster D.R. Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty.Ann Thorac Surg. 2011; 91: 176-178Abstract Full Text Full Text PDF Scopus (22) Google Scholar, 7Caynak B. Onan B. Sagbas E. Duran C. Akpinar B. Cardiac tamponade and pulmonary embolism as a complication of percutaneous vertebroplasty.Ann Thorac Surg. 2009; 87: 299-301Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 8Athreya S. Mathias N. Rogers P. Edwards R. Retrieval of cement embolus from inferior vena cava after percutaneous vertebroplasty.Cardiovasc Interv Radiol. 2009; 32: 817-819Crossref PubMed Scopus (15) Google Scholar These devastating complications due to cement emboli can develop in any patient, so it is necessary to be aware of this potential complication and develop methods of prevention and appropriate treatment. We report a patient with extensive deep vein thrombosis in the IVC, which occurred 10 months after vertebroplasty. He was treated successfully using catheter-directed thrombolysis without removal of the cement inside the IVC. A 69-year-old man was admitted due to left leg swelling for 2 weeks. There was no recent history of major operations, trauma, immobilization, or previous history of deep vein thrombosis. He had a percutaneous vertebroplasty for an L4-5 compression fracture 10 months ago at another hospital. He had no dyspnea or chest pain. Laboratory tests for hypercoagulability demonstrated no abnormality. On physical examination, his left thigh and calf were edematous without inflammation. Computed tomography (CT) angiography revealed a segmental stenosis in the infrarenal IVC and thrombosis extending from the stenotic portion of the IVC to the right common iliac and left common femoral veins (Fig 1, A-D). Two radio-opaque materials were seen: one in the lumbar vein extending into the IVC (0.6 × 6 cm) and the other in the infrarenal IVC wall (0.7 × 6 cm) (Fig 2, A-C). Pulmonary embolism by the radio-opaque material was detected at the subsegmental pulmonary arteries in the left lower lobe (Fig 2, D). Echocardiography showed no abnormalities. He was diagnosed as having IVC thrombosis due to the stenosis, which seemed to be caused by cement leakage during percutaneous vertebroplasty. To avoid invasive procedures, we decided to perform endovascular treatment. First, an IVC filter (Gunther-Tulip; Cook, Bjaeverskov, Denmark) was inserted into the right internal jugular vein and placed in the suprarenal IVC (Fig 3, A and B). Then, a 12F sheath was inserted via the right common femoral vein. Aspiration thrombectomy was performed in the occluded right external iliac vein using a 9F long sheath with a curved tip (Flexor Check-Flo II introducer; Cook, Bloomington, Ind) and a 50-mL syringe. Recanalization to the IVC was ascertained by venography. In the prone position, a 6F sheath was inserted into the left popliteal vein and a 5F infusion catheter (Rothbarth Uni-Flo Infusion catheter; Cook) was advanced up to the right common iliac vein. Urokinase was delivered at 70,000 IU/h via the infusion catheter and 20,000 IU/h of urokinase and 5000 IU/h of heparin were delivered via the sheath. Completion venography after a 16-hour urokinase infusion showed that the thrombi were all resolved (Fig 3, C). Additionally, balloon angioplasty was performed for the stenotic IVC (Fig 3, D). The blood flow improved and reflux into the contralateral lower extremity veins disappeared. Because the luminal narrowing remained, a 20-mm × 6-cm self-expandable stent (S & G Biotech Inc., Seoul, Korea) was placed in the stenotic portion of the IVC (Fig 3, E). The IVC filter was retrieved at the end of the procedure, confirming no entrapped emboli. He was discharged 3 days after the procedure and, with warfarin medication, he has been doing well for 6 months without recurrence of symptoms.Fig 2A, Computed tomography (CT) angiography demonstrated high-density polymethylmethacrylate cement in the lumbar vein extended into the inferior vena cava (IVC) (arrow) and (B) inside the IVC (arrow). C, The coronal view of CT angiography demonstrated two longitudinal cement emboli inside the IVC (arrow). D, The axial chest CT scan shows a radio-opaque material at the subsegmental pulmonary artery in the left lower lobe (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3A, Inferior vena cava (IVC) filter was inserted in the infrarenal IVC. B, Venography showed a segmental severe stenosis in infrarenal IVC. C, Catheter-directed thrombolysis with overnight urokinase infusion was performed. D, Balloon angioplasty for stenotic inferior vena cava was performed. E, A self-expandable stent (20 mm × 6 cm) was inserted to prevent the recurrence of thrombosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Since the introduction of percutaneous vertebroplasty in 1984,9Deramond H. Depriester C. Galibert P. Le Gars D. Percutaneous vertebroplasty with polymethylmethacrylate Technique, indications, and results.Radiol Clin North Am. 1998; 36: 533-546Abstract Full Text Full Text PDF PubMed Scopus (780) Google Scholar the procedure has been widely used for the treatment of vertebral compression fractures caused by osteoporosis or malignant tumors. It involves injection of polymethylmethacrylate into collapsed vertebral bodies with fluoroscopic guidance. Although this procedure is relatively safe, it is associated with pulmonary embolism caused by cement leakage, which is the most common complication.2Krueger A. Bliemel C. Zettl R. Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.Eur Spine J. 2009; 18: 1257-1265Crossref PubMed Scopus (219) Google Scholar A recent study demonstrated that the pulmonary cement embolism remained asymptomatic in the majority of patients.10Venmans A. Klazen C.A. Lohle P.N. van Rooij W.J. Verhaar H.J. de Vries J. et al.Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II.AJNR Am J Neuroradiol. 2010; 31: 1451-1453Crossref PubMed Scopus (106) Google Scholar Kim et al1Kim Y.J. Lee J.W. Park K.W. Yeom J.S. Jeong H.S. Park J.M. et al.Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors.Radiology. 2009; 251: 250-259Crossref PubMed Scopus (171) Google Scholar reported that the incidence of pulmonary embolism, as evaluated by noncontrast CT scans, was 23%, but all patients were asymptomatic. Most of these studies included a small number of patients, and the patients were not routinely evaluated by chest radiography after the procedure. Therefore, the exact frequency of pulmonary embolism was unknown and probably somewhat underestimated. However, it is believed that symptoms related to pulmonary embolism were mild. Although pulmonary cement emboli generally do not affect patient outcome, emboli occurring in the heart or major vessels can lead to catastrophic results. Dash et al6Dash A. Brinster D.R. Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty.Ann Thorac Surg. 2011; 91: 176-178Abstract Full Text Full Text PDF Scopus (22) Google Scholar reported a case of right atrial-IVC thrombosis, which was detected 1 month after percutaneous vertebroplasty and was successfully treated with open heart surgery. Caynak et al7Caynak B. Onan B. Sagbas E. Duran C. Akpinar B. Cardiac tamponade and pulmonary embolism as a complication of percutaneous vertebroplasty.Ann Thorac Surg. 2009; 87: 299-301Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar reported a case which developed a delayed tamponade due to cement material 2 months after the procedure and underwent surgical removal.7Caynak B. Onan B. Sagbas E. Duran C. Akpinar B. Cardiac tamponade and pulmonary embolism as a complication of percutaneous vertebroplasty.Ann Thorac Surg. 2009; 87: 299-301Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Krueger et al2Krueger A. Bliemel C. Zettl R. Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.Eur Spine J. 2009; 18: 1257-1265Crossref PubMed Scopus (219) Google Scholar suggested treatment guidelines for cement embolism in terms of symptoms and locations. They recommended no treatment for asymptomatic patients with peripheral emboli. Initial intravenous heparinization followed by warfarin therapy for 6 months should be considered for patients with any symptoms or central emboli in the heart or lung.2Krueger A. Bliemel C. Zettl R. Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.Eur Spine J. 2009; 18: 1257-1265Crossref PubMed Scopus (219) Google Scholar Although this treatment strategy is based on previously reported literature, the level of evidence is low. Further studies with a large number of patients are needed to establish useful guidelines; however, this seems to be unrealistic due to the rare incidence of the complicated cases. In our case, the leaked cement migrated to the IVC and pulmonary artery. To decide on the optimal treatment method, sequential mechanisms for this situation should be considered. Considering the time interval between the procedure and symptom onset, it seemed that leaked cement adhered to the vessel wall of the IVC and caused inflammatory reactions in the endothelium and resulted in IVC stenosis. If the stenosis was resolved and the possibility of recurrence due to inflammatory reactions was eliminated, surgical embolectomy was not absolutely necessary. Endovascular treatments, including aspiration thrombectomy, thrombolysis, and stenting, were successful to this subacute lesion. To the best of our knowledge, this is the first report of successful endovascular treatment of delayed thrombosis caused by cement migrating to the IVC. To establish safer treatment methods for these complications caused by cement leakage, vascular surgeons and radiologists, especially neuroradiologists, should be aware of the mechanism of intravascular migration of leaked cement. Since liquid polymethylmethacrylate cement tends to leak, it should be mixed to be highly viscous.2Krueger A. Bliemel C. Zettl R. Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.Eur Spine J. 2009; 18: 1257-1265Crossref PubMed Scopus (219) Google Scholar, 11Baroud G. Crookshank M. Bohner M. High-viscosity cement significantly enhances uniformity of cement filling in vertebroplasty: an experimental model and study on cement leakage.Spine. 2006; 31: 2562-2568Crossref PubMed Scopus (174) Google Scholar Percutaneous vertebroplasty should be performed under fluoroscopic guidance by an experienced specialist. Cement migration to the azygous vein or IVC shows a significant correlation with pulmonary cement embolism. Therefore, when cement migration to the paravertebral space is noticed, interventionists should stop the injection.1Kim Y.J. Lee J.W. Park K.W. Yeom J.S. Jeong H.S. Park J.M. et al.Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors.Radiology. 2009; 251: 250-259Crossref PubMed Scopus (171) Google Scholar, 2Krueger A. Bliemel C. Zettl R. Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.Eur Spine J. 2009; 18: 1257-1265Crossref PubMed Scopus (219) Google Scholar, 8Athreya S. Mathias N. Rogers P. Edwards R. Retrieval of cement embolus from inferior vena cava after percutaneous vertebroplasty.Cardiovasc Interv Radiol. 2009; 32: 817-819Crossref PubMed Scopus (15) Google Scholar Screening the patients routinely with chest radiography or CT scan after the vertebroplasty is controversial. Some investigators insist that the screening is not necessary because early detection by screening does not have any clinical significance for asymptomatic patients.10Venmans A. Klazen C.A. Lohle P.N. van Rooij W.J. Verhaar H.J. de Vries J. et al.Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II.AJNR Am J Neuroradiol. 2010; 31: 1451-1453Crossref PubMed Scopus (106) Google Scholar Here, we reported a case of IVC stenosis and delayed thrombosis caused by migrated cement materials during vertebroplasty. Delayed vascular events can occur after vertebroplasty, and endovascular treatment can be a good treatment option.