Vertebroplasty-associated cement leak leading to iatrogenic venous compression and thrombosis

Abstract

A 91-year-old woman presented with left lower extremity swelling and pain diagnosed as phlegmasia cerulea dolens. Doppler ultrasound and venography revealed extensive left lower extremity deep venous thrombosis. Review of prior images revealed cement leakage causing compression of the left common iliac vein. She underwent successful mechanical thrombectomy using the ClotTriever device (Inari Medical, Irvine, Calif) and subsequent stent placement. Phlegmasia cerulea dolens resolved on the following day, and the stent remained patent at the 1-month follow-up appointment. Cement leakage from L5 vertebroplasty can cause extrinsic compression on the left common iliac vein, resulting in iatrogenic venous compression syndrome and the development of deep venous thrombosis in the affected lower extremity.

Keywords: Cement leakage; Common iliac vein; Deep venous thrombosis; Stenosis; Venous compression syndrome; Vertebroplasty.

Fig 1

Axial image of non-contrast-enhanced computed tomography (CT) scan of the pelvis approximately 2 years after vertebroplasty shows extravertebral leakage of the cement (yellow arrow), mass effect over the left common iliac vein (blue arrow), and left common iliac artery (red arrow).

Fig 2

Schematic picture of the Inari ClotTriever thrombectomy device. The Inari ClotTriever thrombectomy device includes a self-deployed funnel (A) and a thrombectomy catheter (B). The ClotTriever catheter was advanced through the ClotTriever sheath, beyond the thrombosed segments, just distal to the inferior vena cava (IVC) confluence. The nitinol coring element with the attached collection bag, the essential thrombectomy component of the ClotTriever catheter, was then deployed and slowly retracted toward the sheath.

Fig 3

A, Preliminary venography of the left lower extremity. Catheter venogram showed patency of the distal and mid femoral vein but confirmed extensive thrombosis extending from proximal left femoral vein through left common iliac vein. B, Mechanical thrombectomy. The retrieval nitinol net of the Inari ClotTriever thrombectomy device (Inari Medical Inc, Irvine, Calif) was deployed and the system retracted into the sheath. C, A significant amount of acute and chronic clots was retrieved using the Inari ClotTriever device. D, Final venography shows improved blood flow in the left common iliac vein stent but mass effect from cement leakage.

Fig 4

Pictures of left lower extremity before and after thrombectomy show significant improvement of the left lower extremity phlegmasia cerulea dolens.

Fig 5

Computed tomography (CT) venography of the pelvis. Axial view demonstrates cement leakage from L5 vertebroplasty causing 40% to 50% luminal stenosis; the left common external iliac vein stent is patent.