Differences between Pulmonary and Intracardiac Cement Embolism Migration after Percutaneous Cementoplasty: Report of Two Cases and Review of the Literature

Background: Percutaneous procedures using Polymethylmethacrylate (PMMA) cement are successfully used to treat vertebral compression fractures. Although it is a minimally invasive procedure, complications can occur. Cement embolism is a serious adverse event, and migration of PMMA most often occurs in the pulmonary arterial system, resulting in cement pulmonary embolism. However, intracardiac cement embolism migration is a rare and life-threatening complication that has been described in few case reports1. To the best of our knowledge, differences in migration patterns between pulmonary and intracardiac cement embolism have not been described.

Methods: We report two cases of cement embolism after percutaneous cementoplasty using Spine Jack^® device and PMMA cement. The first case was a 49-year-old female known for a T cell Lymphoma operated for T10 and L5 vertebral compression fractures. The second case was a 66-year-old female operated for an L1 osteoporotic fracture. Clinical and radiological presentation of both cases are compared, and intracardiac cement embolism case reports are reviewed.

Results: In both cases, cement leakage was identified in a paravertebral vein during the procedure, and injection was immediately aborted. However, post-operative clinical course differed. In the first case, the patient was immediately transferred to the radiology unit after the procedure. A transesophageal echocardiography (TEE), followed by angiography, revealed an inferior lobar artery cement embolism. In the second case, presentation consisted of insidious chest pain and discomfort, several hours after the end of the procedure. Echocardiography revealed an intracardiac cement embolism, anchored to the tricuspid valve. In the literature as well, most of the case reports concerning intracardiac cement embolism describe a delayed clinical presentation. Of note, the risk of an asymptomatic cement embolism ranges from 3.5 to 23%. Symptomatic cement embolism is much more rare. In our institution, there were only two cases over around 1700 procedures.

Conclusion: We present two different cases of cement embolism following percutaneous cementoplasty procedures. We believe that clinical presentation differs between intracardiac and pulmonary cement migration. Intracardiac cement embolism is rare, and presentation is often delayed. It is important to keep a high level of suspicion, especially when paravertebral venous cement leakage is identified during the procedure.