Unexpected finding in computed tomographic pulmonary angiography

IMAGE IN MEDICINE

Unexpected finding in computed tomographic pulmonary angiography

Thiago Horta Soares^I; Marcos de Bastos^II; Wanderval Moreira^III; Suely Meireles Rezende^IV

^IHospital Mater Dei; Department of Internal Medicine, Grupo de Estudo da Hemostasia e Trombose (GETHe), Faculty of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil

^IIInstituto de Previdência do Estado de Minas Gerais, Department of Internal Medicine, GETHe, Faculty of Medicine, UFMG, Belo Horizonte, MG, Brazil

^IIIHospital Mater Dei, Belo Horizonte, MG, Brazil

^IVDepartment of Internal Medicine, GETHe, Faculty of Medicine, UFMG, Belo Horizonte, MG, Brazil

^{Correspondence to}

A 78-year-old woman was admitted to the hospital with nausea and abdominal pain. She had a history of lumbar fracture secondary to corticosteroid use and underwent an uneventful vertebroplasty at L1-L2 three months before admission. Laboratory tests and an abdominal computerized tomography showed acute pancreatitis.

Three days later, she complained of dyspnea and had a transient thoracic pain. No hemodynamic instability was detected. A thorax computed angiotomography was performed, which showed dense intravascular masses located inside the arteries for the right superior, inferior, and middle lobes, suggestive of pulmonary cement emboli (PCE) (Figure 1). Respiratory symptoms disappeared and no relation was found between PCE and actual symptoms. The patient was submitted to a cholecystectomy, and recovered well.

PCE is a possible systemic complication associated with vertebroplasty or kyphoplasty¹. The reported prevalence (4.6% to 23%) may be an underestimation, as PCE screening is not routinely undertaken^2-3. Cement emboli may reach the pulmonary circulation through the perivertebral venous system, the azygos and cava veins¹. Its clinical presentation varies from an asymptomatic picture to sudden death^1-3. The management of PCE is not well established. No treatment is indicated in asymptomatic patients, but surgical removal, heparinization, or anticoagulation with vitamin K antagonists may be considered⁴.

It is suggested that PCE may be prevented by appropriate patient selection for surgery, improved surgical techniques, and good image screening by fluoroscopy during the procedure^1-4.

Study conducted at Hospital Mater Dei, Belo Horizonte, MG, Brazil

References

• 1. Lee IJ, Choi AL, Yie MI, Yoon JY, Jeon EY, Koh SH, et al. CT evaluation of local leakage of bone cement after percutaneus kyphoplaty and vertebroplasty. Acta Radiol. 2010;51(6):649-54.
• 2. Kim YJ, Lee JW, Park KW, Yeom js, Jeong HS, Park JM, et al. Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors. Radiology. 2009;251(1):250-9.
• 3. Chen HL, Wong CS, Ho ST, Chang FL, Hsu CH, Wu CT. A lethal pulmonary embolism after percutaneous vertebroplasty. Anesth Analg. 2002;95(4):1060-2.
• 4. Krueger A, Bliemel C, Zettl R, Ruchholtz S. Management of pulmonary cement after percutaneus vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J. 2009;18(9):1257-65.

Publication Dates

• Publication in this collection
  17 Oct 2012
• Date of issue
  Oct 2012