Mr. J. is a 79‐year‐old man with a history of pulmonary embolism (PE)/deep vein thrombosis (DVT), coronary artery disease status post coronary artery bypass graft with ICM ejection fraction (EF) of 36% in 2007, AS, 2 cerebrovascular accidents, hypertension, HL, and osteoporosis with multiple vertebral compression fractures status post L4/L5 percutaneous vertebroplasty (PVP) admitted with weakness and acute worsening of his chronic shortness of breath, which started 3 days prior to admission when walking up the stairs to his room with his cane. He called the heart failure clinic, and they recommended a dose of Lasix 20 mg. He did so with good response (>700 cc urine output), but did not feel better and thus came to the emergency department (ED). In the ED his SaO2 was 93% on room air, and he appeared comfortable. He felt better with oxygen. He underwent electrocardiography and blood work. He was admitted for further evaluation with a pending pulmonary embolism (PE) CT. PE CT showed interval development of numerous pulmonary cement emboli (PCE). High‐density cement was seen in the L4–L5 region; there was also a strand of high‐attenuation material extending into the inferior vena cava (IVC). He also underwent transthoracic echocardiography (TTE), which indicated moderate to severe aortic stenosis (AS) and left ventricular hypertrophy with mildly decreased left ventricular systolic function (EF, 46%). Although systolic function was stable if not improved (prior EF, 36%), the AS was increased from prior TTE done 2 years ago. As the worsened AS was likely subacute in nature, there was concern that the cement emboli were the cause of the patient's acute symptoms. Pulmonary was consulted regarding the need for anticoagulation (recommended treatment with heparin transitioned to 6 months of warfarin), and interventional radiology (IR) was consulted for IVC filter placement given cement extending into the IVC. The patient declined anticoagulation. He was, however, amenable to IVC filter placement. IR placed a bird's nest filter, which would be most likely to catch a dislodged particulate cement fragment. The patient was discharged to subacute rehabilitation.
PV P and balloon kyphoplasty (BKP) are relatively new orthopedic procedures shown to be of benefit in pain management, especially with osteoporotic fractures. Transvertebral leakage of cement into surrounding soft tissues and extension into the veins is common: up to 90% in PVP and up to 37.5% in BKP. The incidence of cement emboli is estimated to be from 3.5% to 23% for osteoporotic fractures. There are no clear guidelines for workup or management of PCE. A review of the literature indicates that asymptomatic PCE do not need to be treated. Symptomatic PCE, however, should likely be treated according to guidelines for throm‐botic PEs to avoid further thrombosis from the cement. By completion of the 6 months, the thrombus should be endothelialized. Surgical embolectomy should only be considered in particular cases (e.g., perforated right ventricle).
The incidence of both cement extravasation and PCE is underestimated following PVP and BKP. Hospitalists should consider PCE in a patient with a history of these procedures presenting with acute onset of dyspnea. Management should be based on the degree of symptomaticity.
J. G. Dastidar ‐ none
To cite this abstract:Dastidar J. History of Pe/dvt + Vertebroplasty + Dyspnea = ?. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 261. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/history-of-pedvt-vertebroplasty-dyspnea/. Accessed March 20, 2019.