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Case Report |
1 All authors: Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-2dong, Songpa-gu, Seoul 138-736, South Korea.
Received September 10, 2004;
revised October 26, 2004;
Address correspondence to J. B. Seo
(seojb{at}amc.seoul.kr).
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Multiplanar reformatted images from the axial data reconstructed in mid-diastole showed two radiopaque linear materials in the right atrium and right ventricle, respectively (Fig. 1B). That in the right ventricle perforated the right ventricular free wall and caused hemopericardium. In addition, CT revealed the presence of cement material cast in the perivertebral veins, which was the origin of the leak, and in the azygos vein (Fig. 1C). Multiple tubular emboli in the pulmonary arteries were also noted (Fig. 1D).
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There is always a potential risk of cement migration into the vena cava, which may result in pulmonary embolism. Vasconcelos et al. [7] reported the incidence of minor passage of cement into perivertebral veins as 16.6%, including one case in which a minute amount of cement reached the inferior vena cava (0.5%). They said those data probably underestimate the true frequency of minute PMMA leakage because a minor leak may go undetected or may not be recorded as such in the procedural report.
The possible mechanisms of cement embolism are insufficient polymerization of the PMMA at the time of the injection, the needle position with respect to the basivertebral vein, and overfilling of the vertebral body, which facilitates cement migration into the venous system [3]. Several cases of cement pulmonary embolism [3–5] and one case of cerebral embolism [6] related to percutaneous vertebroplasty have been reported. Although pulmonary embolism caused by PMMA is usually asymptomatic, there have been clinically significant pulmonary emboli [3, 5] even requiring open pulmonary artery embolectomies [6]. The frequency of this complication may be increased by the widespread use of percutaneous vertebroplasty.
To our knowledge, this is the first case report of cardiac perforation caused by migrated cement, a potentially fatal complication after vertebroplasty. It is not surprising that this complication can occur when we consider that all pulmonary emboli pass through the right-sided cardiac chambers. If the cement reaching the right ventricle is too long and stiff to go into the pulmonary artery, it may stay in the heart. Perforation of the right ventricular free wall was probably due to the sharp end of the cement combined with continuous cardiac contraction.
Recently, CT of the heart moved into the diagnostic realm because of the introduction of MDCT and the development of ECG-synchronized scanning and reconstruction techniques [8]. Using these techniques, we were able to preoperatively evaluate the exact location, number, and shape of the pieces of cement string in the heart of our patient even when her heart rate was up to 100 beats per minute; these imaging findings corresponded well with the operative findings in this case. In particular, MDCT accurately showed the cement material in the right atrium, which was not detected on echocardiography. This case shows the usefulness of ECG-gated MDCT to evaluate a foreign body in the heart. In addition, we were able to evaluate the extent of the pulmonary embolism caused by the cement material on reconstructed images from the same data set.
To avoid venous extravasation of cement and resulting complications, meticulous techniques of vertebroplasty are required [4]. First, only cement of the appropriate viscosity should be injected. Second, a high-resolution fluoroscope and mixing of the PMMA with barium or tungsten for opacification are essential for early detection of venous PMMA migration. Third, if vertebral venography identifies a direct shunt from the needle tip to the venous system, repositioning of the needle tip and insertion of gelatin particles (Gelform, Upjohn) may be helpful in preventing venous leakage.
In summary, we report a case of cardiac perforation and pulmonary embolism caused by migrated cement used for vertebroplasty. ECG-gated cardiac MDCT clearly showed the location and amount of the cement in the heart, thus facilitating an appropriate surgical approach. Conducting the procedure with the utmost care and appropriate monitoring should be used to avoid extravasation of cement during vertebroplasty.
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