Transcatheter Removal of Bone Cement Embolism in the Right Atrium after Percutaneous Vertebroplasty: The Embolus Broke in Half and Migrated to the Right Pulmonary Artery Intraoperatively

Abstract

Bone cement embolism often occurs during percutaneous vertebroplasty. Bone cement pulmonary arterial embolism generally requires no treatment because of the small size and asymptomatic manifestation. Intracardiac bone cement embolisms are rare but associated with a risk of severe complications. Intracardiac bone cement embolisms are mainly removed through open heart surgery. To the best of our knowledge, only three cases of intracardiac bone cement embolisms removed with interventions have been reported. Here, we report another case of successful transcatheter retrieval of a 6-cm-long cement embolism in the right atrium after percutaneous vertebroplasty. The embolus broke in half and migrated to the right pulmonary artery intraoperatively. Using two snares and a filter retrieval device, we advanced from opposite directions. Further, we gently grasped and pulled the fragments of the right pulmonary artery and aligned them in a linear fashion directly into the sheath for uneventful removal.

Keywords: Bone Cements; Embolism; Endovascular Procedures; Right Atrium; Vertebroplasty.

Fig. 1. A 72-year-old male with a foreign body in the RA, identified as bone cement embolism.

A. Left lateral view of chest radiography shows a curvilinear opacity (white arrow) in the RA. Further, it shows bone cements injected into the lumbar vertebrae (black arrows) with possible extravasation of cement from the L2 to the inferior vena cava (arrowhead). B. Two-chamber view of cardiac CT with contrast enhancement shows a bright curvilinear bone cement embolism in the RA, adjacent to the inferior wall (arrow). C. Fluoroscopic spot image demonstrates an embolus (arrow) within the RA. D. The embolus is broken in half, and the fragments (arrows) have migrated to the right pulmonary artery. RA = right atrium E. The emboli were removed using the two-snare technique: the left embolus first and then the right embolus. The two snares were aligned with the embolus to pass through the vertically oriented sheath. The internal jugular snare (white arrows), embolus (white arrowheads), and femoral filter retrieval device (left, black arrow)/snare (right, black arrow) are seen. F. Clinical photograph shows a 6-cm-long U-shaped cement material, with the arms measuring 3.5 cm and 2.5 cm, which was finally removed from the right pulmonary artery. RA = right atrium