13 May 2016: Articles 
Intracardiac Leakage of Cement During Kyphoplasty and Vertebroplasty: A Case Report
Challenging differential diagnosis, Diagnostic / therapeutic accidents, Educational Purpose (only if useful for a systematic review or synthesis), Rare coexistence of disease or pathology
Ziad A. Audat ABCDEFG , Mohammad D. Alfawareh F , Fayeq T. Darwish ABF , Ali A. Alomari ACFDOI: 10.12659/AJCR.897719
Am J Case Rep 2016; 17:326-330
Abstract
BACKGROUND: Intracardiac leakage of bone cement after kyphoplasty and vertebroplasty is a rare and life-threatening complication. Cortoss, which is an injectable, non-absorbable, polymer composite that is designed to mimic cortical bone, can be used instead of cement. Here, we present the case of a patient with right intra-cardiac Cortoss embolization.
CASE REPORT: A 28-year-old man known to have ulcerative colitis since the age of 15 and treated with corticosteroids for more than 4 years and with anti-immune drugs presented to our hospital complaining of back pain and decreased body height due to osteomalacia with failed conservative treatment. Kyphoplasty and vertebroplasty of the thoracic 10–12 and first lumbar vertebrae were done with any complications. Three months later, the patient underwent kyphoplasty and vertebroplasty of lumbar 2–5 vertebrae by injecting Cortoss instead of cement, which was complicated with paravertebral intravascular leakage. We stopped surgery and transferred him to the recovery room, where he had slight chest pain that resolved spontaneously without neurological deficit. Two days later he developed severe chest pain and chest X-ray showed a large white shadow at the right side of the heart and another 2 small shadows just lateral to it. Sudden deterioration of patient status necessitated an emergency echocardiogram, which showed pericardial tamponade and a perforated right ventricle. Aspiration of pericardial blood and emergency open heart surgery were done. He was discharged 4 days later and was followed up at an outpatient clinic.
CONCLUSIONS: Cardiac embolism is a serious condition that can complicate vertebral kyphoplasty; it requires a high level of suspicion and immediate action, and may need open heart surgery to save the patient’s life.
Keywords: Bisphenol A-Glycidyl Methacrylate, Embolism - etiology, Foreign-Body Migration - etiology, Heart Diseases - etiology, Intraoperative Complications, Kyphoplasty - adverse effects, Vertebroplasty - adverse effects
Background
Percutaneous vertebroplasty is a minimally invasive procedure used to treat back pain and prevent deformity secondary to osteoporotic fractures or destructive lesions [1,2]. In rare cases, the cement leaks anterior and lateral to the vertebral body; this leakage can be intra-disc, intraspinal, or intravascular [3,4]. Cement inside the vessels can reach the heart, pulmonary circulation, or even cerebral circulation [5,6]. Intra-cardiac cement leakage is very rare and few cases are found in the literature. Cortoss is an injectable, non-resorbable, polymer composite that is designed to mimic cortical bone material instead of bone cement. Cortoss is the best artificial material for this use; it has nearly the same compressive and tensile strength as cortical bone and it enhances formation of bone on its surface [7–10]. Here, we describe a case of intra-cardiac embolism of Cortoss 2 days after surgery.
Case Report
We report the case of a 28-year-old male patient who was diagnosed with ulcerative colitis at age 15 years. He had been treated conservatively with corticosteroids for over 4 years, and had also received anti-immune drugs. Over time he developed hip pain (due to avascular necrosis of the femoral head), back pain, and loss of trunk height due to adverse drug effects. Bone Dexa-scan, X-rays, and MRI of the spine revealed osteomalacia without spinal canal or nerve root canal stenosis, multilevel biconcave vertebrae, and multilevel vertebral compression fractures (Figures 1, 2). Conservative treatment with alendronate, vitamin D, and Calcium for more than 3 years failed to control back symptoms and gradual shortening of stature. We discussed with the patient performance of kyphoplasty and vertebroplasty of thoracic 10–12 and first lumbar vertebrae. This was performed in a single session by injecting methyl methacrylate, without complications.
After 3 months the patient was readmitted for vertebroplasty and kyphoplasty of lumbar spine 2–5. At that time, we discussed with the patient the use of Cortoss because it is designed to mimic cortical bone material and enhance bone formation on its surface. The procedure was aborted and injection of Cortoss was ceased because of paraspinal intravascular leakage (Figure 3). In the recovery room, the patient did not have any neurological deficit or dyspnea, just non-significant chest pain that resolved after full recovery with simple analgesia.
Two days later, he developed progressive chest pain, dyspnea, and tachycardia. A chest X-ray showed a white shadow (about 5 centimeter) at the right side of the heart and 2 small shadows at the right lung hilum, and an echocardiogram showed pericardial effusion (Figure 4). Suddenly, he deteriorated and went into shocked, requiring aspiration of pericardial effusion, as recommended by the cardiologist to save the patient’s life. Later, patient underwent urgent open heart surgery to remove the Cortoss from the right side of the heart and right pulmonary artery (Figure 5). The patient had an uneventful recovery. His condition improved and he was discharged on the 4th post-operative day and was followed up at an outpatient clinic.
Discussion
Intracardiac cement embolism is a rare complication after vertebroplasty or kyphoplasty. We reviewed the literature and found only 15 case reports of intra-cardiac cement embolism [11–25]. Most of the cases were diagnosed during or within a short period after surgery, except for 1 diagnosed 2.5 years after kyphoplasty because of pericardial perforation [23]; cement reached the heart and lodged inside the right atrium or ventricle and in 1 case cement lodged in the ventricular septum [17]. The sequelae of the cardiac embolism are: perforation, pericardial tamponade, or pericardial perforation, which may cause chest pain, dyspnea, and shock [13,14,16,17,20,23]. All patients underwent open-heart surgery except for 1 in whom cement was removed by catheterization [12].
Our patient developed chest pain immediately after surgery. The pain was relieved by simple analgesia. At 2 days post-surgery, the pain suddenly increased, with sweating and severe hypotension due to ventricular wall perforation by myocardial contraction on the sharp ends of the Cortoss, which resulted in pericardial tamponade demonstrated by echocardiogram and pericardial aspiration.
Emergency life-saving surgery was done to remove the Cortoss pieces and repair the heart wall. To the best of our knowledge, this is the first case of Cortoss (rather than regular cement) cardiac embolism as a complication of kyphoplasty and vertebroplasty. This shows that both cement and Cortoss can cause heart embolism after it changes from paste during injection into a hard substance.
Conclusions
Cardiac embolism is a serious condition that can complicate vertebral kyphoplasty. It needs a high level of suspicion, and requires immediate actions, including open heart surgery, to save the patient’s life.
References:
1.. Kim HT, Kim YN, Shin HW, Intracardiac foreign body caused by cement leakage as a late complication of percutaneous vertebroplasty: Korean J Intern Med, 2013; 28(2); 247-50, pmid: 23526735
2.. Jensen ME, Evans AJ, Mathis JM, Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects: Am J Neuroradiol, 1997; 18; 1897-904, pmid: 9403451
3.. Mathis JM, Percutaneous vertebroplasty: complication avoidance and technique optimization: Am J Neuroradiol, 2003; 24(8); 1697-706, pmid: 13679295
4.. Mathis JM, Barr JB, Belkoff SM, Percutaneous vertebroplasty: A developing standard of care for vertebral compression fractures: Am J Neuroradiol, 2001; 22; 373-81, pmid: 11156786
5.. Al-Nakshabandi NA, Percutaneous vertebroplasty complications: Ann Saudi Med, 2011; 31(3); 294-97, pmid: 21623061
6.. Laredo JD, Hamze B, Complications of percutaneous vertebroplasty and their prevention: Skeletal Radiol, 2004; 33(9); 493-505, pmid: 15205925
7.. Bae H, Shen M, Maurer P, Clinical experience using Cortoss for treating vertebral compression fractures with vertebroplasty and kyphoplasty: twenty four-month follow-up: Spine (Phila Pa 1976), 2010; 35(20); E1030-36, pmid: 20844420
8.. Boyd D, Towler MR, Wren A, Clarkin OM, Comparison of an experimental bone cement with surgical Simplex P, Spineplex and Cortoss: J Mater Sci Mater Med, 2008; 19(4); 1745-52, pmid: 18197364
9.. Middleton ET, Rajaraman CJ, O’Brien DP, The safety and efficacy of vertebroplasty using Cortoss cement in a newly established vertebroplasty service: Br J Neurosurg, 2008; 22(2); 252-56, pmid: 18348022
10.. Bae H, Hatten HP, Linovitz R, A prospective randomized FDA-IDE trial comparing Cortoss with PMMA for vertebroplasty: A comparative effectiveness research study with 24-month follow-up: Spine (Phila Pa 1976), 2012; 37(7); 544-50, pmid: 21738093
11.. George KM, Campbell M, Embolized methyl methacrylate to the right atrium after kyphoplasty: Ann Thorac Surg, 2015; 99(1); 337, pmid: 25555963
12.. Grifka RG, Tapio J, Lee KJ, Transcatheter retrieval of an embolized methylmethacrylate glue fragment adherent to the right atrium using bidirectional snares: Catheter Cardiovasc Interv, 2013; 81(4); 648-50, pmid: 22566411
13.. Dreger H, Treskatsch S, Lembcke A, Perforation of the right ventricle by bone cement: A rare complication of kyphoplasty: Eur Heart J, 2013; 34(16); 1203, pmid: 23197568
14.. Mattis T, Knox M, Mammen L, Intracardiac methylmethacrylate embolism resulting in right atrial wall perforation and pericarditis following percutaneous vertebroplasty: J Vasc Interv Radiol, 2012; 23(5); 719-20, pmid: 22525028
15.. Cohen JB, Bone cement embolism: Anesthesiology, 2012; 117(2); 407, pmid: 22388069
16.. Gosev I, Nascimben L, Huang PH, Right ventricular perforation and pulmonary embolism with polymethylmethacrylate cement after percutaneous kyphoplasty: Circulation, 2013; 127(11); 1251-53, pmid: 23509033
17.. Kim MN, Jung JS, Kim SW, A sword-like foreign body lodged in the ventricular septum: A rare complication of percutaneous vertebroplasty: Eur Heart J, 2010; 31(8); 1006, pmid: 20019023
18.. Farahvar A, Dubensky D, Bakos R, Perforation of the right cardiac ventricular wall by polymethylmethacrylate after lumbar kyphoplasty: J Neurosurg Spine, 2009; 11(4); 487-91, pmid: 19929347
19.. Kim HT, Kim YN, Shin HW, Intracardiac foreign body caused by cement leakage as a late complication of percutaneous vertebroplasty: Korean J Intern Med, 2013; 28(2); 247-50, pmid: 23526735
20.. Tran I, Gerckens U, Remig J, First report of alife-threatening cardiac complication after percutaneous balloon kyphoplasty: Spine (Phila Pa 1976), 2013; 38(5); E316-18, pmid: 23232213
21.. García-Fontán E, Blanco Ramos M, Obeso Carillo GA, Cement embolism during a kyphoplasty: Eur J Cardiothorac Surg, 2013; 44(1); 183, pmid: 23337329
22.. Cohen J, Lane T, Right intra-atrial and ventricular polymethylmethacrylate embolus after balloon kyphoplasty: Am J Med, 2010; 123(10); e5-6, pmid: 20920681
23.. Prokop A, Hägele M, Pfeilsticker U, [Pericardial perforation 2.5 years after kyphoplasty. A rare complication after cemente xtravasation]: Unfallchirurg, 2013; 116(1); 80-84, pmid: 22367516 [in German]
24.. Lee JS, Jeong YS, Ahn SG, Intracardiac bone cement embolism: Heart, 2010; 96(5); 387, pmid: 20197363
25.. Dash A, Brinster DR, Open heart surgery for removal of polymethylmethacrylate after percutaneous vertebroplasty: Ann Thorac Surg, 2011; 91(1); 276-78, pmid: 21172531
In Press
Case report 
Am J Case Rep In Press; DOI: 10.12659/AJCR.949976
Case report 
Am J Case Rep In Press; DOI: 10.12659/AJCR.950290
Case report 
Am J Case Rep In Press; DOI: 10.12659/AJCR.950607
Case report 
Am J Case Rep In Press; DOI: 10.12659/AJCR.950985
Most Viewed Current Articles
07 Dec 2021 : Case report 
17,691,734
DOI :10.12659/AJCR.934347
Am J Case Rep 2021; 22:e934347
06 Dec 2021 : Case report 
164,491
DOI :10.12659/AJCR.934406
Am J Case Rep 2021; 22:e934406
21 Jun 2024 : Case report
113,090
DOI :10.12659/AJCR.944371
Am J Case Rep 2024; 25:e944371
07 Mar 2024 : Case report
59,175
DOI :10.12659/AJCR.943133
Am J Case Rep 2024; 25:e943133