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Pulmonary Cement Embolism and Active Bleeding After Percutaneous Vertebroplasty for Osteoporotic Vertebral Fractures in a Young Patient with Lung Transplant Rejection. Clinical Management and Outcome 2014

Category Interventional Matteo Bellini
Daniele Giuseppe Romano
Marco Ferrara
David Bennett
Antonella Fossi
Luca Voltolini
Francesco Vigni
Carmelo Ricci
Alfonso Cerase
Paola Rottoli
Purpose To discuss indication, efficacy, and clinical management of relevant complications of percutaneous vertebroplasty (PVP) in a young patient with lung transplant rejection (LTr). Materials & Methods A 46-year-old male with LTr had a two-week history of significant back pain (VAS score: 9), refractory to medical and conservative therapy, and was forced to bed-rest, i.e. a contraindication during transplant rejection. Thoracolumbar spinal CT and MRI showed 3 partial vertebral compression fractures (L1, L3, and L4). History revealed diffuse vertebral osteopenia due to corticosteroid therapy for pulmonary fibrosis, worsened in osteoporosis after LTr. PVP was indicated for both pain relief and vertebral augmentation, considering the increased risk of general complications in these patients. Treatment was performed under local anesthesia, routinary antibiotic prophylactic regimen, and fluoroscopic guidance, with patient prone, and using a 13G vertebroplastic needle by a monolateral transpeduncolar approach. High viscosity polymethylmethacrylate (PMMA) cement was injected. Also L2 vertebra, due to patient’s weight (100 kg), in order to reduce the risk of “sandwich” collapse. Results The patient had an immediate symptoms improvement (VAS score: 1). PMMA leakages occurred in two different lumbar veins: these looked apparently stable, however 4 minutes after stopping PMMA injection an unexpected cement migration occurred from the third vertebra treated (L2). Contrast-enhanced CT showed PMMA embolization across the main pulmonary arteries which were not occluded. In agreement with the other physicians, systemic prophylactic heparin was administered. One day later, the patient referred relevant back pain in the left dorsal-lumbar region skin due to a large muscle hematoma. Color-Doppler ultrasound showed an active arterial bleeding, apparently not at bites site. Heparin was immediately stopped. Rapid anemization (hemoglobin: 5) led to a successful endovascular embolization of a left lumbar artery. The hematoma had a significant volume reduction in some days. At two-week follow-up, chest radiographs showed stable PMMA and the patient remained asymptomatic. Conclusion There are no guidelines for the management of pulmonary cement embolism, notably in LTr patients. Osteoporosis-induced vertebral fractures have the potential to compromise LT outcome by rendering a patient nondeambulatory and narcotic-dependent. The risk of vertebral collapses is described after transplants rejection due to secondary osteoporosis induced by corticosteroid administration and immunosuppressive drugs. Despite the rate of complications, in these patients PVP can be effective as pain relief and reducing the risk of side effects after long-term of bed-rest. References A Krueger et al. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J 2009;18:1257–65