Quickshot: Endovascular Management of Vertebroplasty Cement Embolism: Case Report and Review of Literature

Percutaneous vertebroplasty and kyphoplasty to treat vertebral fractures have become a mainstay in the management of osteoperotic or neoplastic spinal fractures. These image guided minimally invasive procedures have become the preferred method to managing debilitating fractures in elderly and frail individuals. Despite their excellent outcomes and low overall risk, these procedures are not without complications. Venous cement leakage and resultant venous embolism as a result of vertebroplasty have reported rates beyond 50%, with a fraction of these resulting in pulmonary embolism.

Here, we present a case of a 70 year old patient with osteoperotic vertebral fractures who underwent L1-L5 percutaneous kyphoplasty with Polymethylmethacrylate (PMMA) cement. The patient tolerated the procedure well, but on re-presentation was found to have imaging findings demonstrating venous cement embolism involving the inferior vena cava, right renal vein, and bilateral common iliac veins (Figure 1, 2). 

Methods: We reviewed 20 articles in the existing literature extracted from the PUBMED database with MeSH terms ‘vertebroplasty’ ‘kyphoplasty’ ‘cement embolism’ and ‘management’ to review current management guidelines on endovascular cement embolism.

Results: Polymethylmethacrylate (PMMA) cement leakage, is a common complication of after vertebral augmentation (VA) with percutaneous kyphoplasty or vertebroplasty. Potential complications include pulmonary cement embolism and intra-cardiac embolism. Adequate imaging utilizing CTA of the chest, contrast-enhanced CT abdomen, and pelvis, or Angiography should be utilized to asses the extent of the embolism. Approaches to treatment, range from observation and anticoagulation to surgical intervention. Surgical options include endovascular retrieval with snare and IVC filter placement. Hybrid procedures like open endovascular procedures can also be utilized in extensive cases.

Conclusions: In managing cement embolism following kyphoplasty and vertebroplasty, proactive interventions such as the use of IVC filters and careful emboli retrieval techniques are crucial to prevent potential complications such as pulmonary embolism. Comprehensive risk assessment and procedural preparedness are essential to ensure optimal patient outcomes.