Chronic Pulmonary Thromboembolism as a Consequence of Cement Embolization

Abstract

INTRODUCTION: Localized cement leakage is known complications of kyphoplasty but cement embolization in pulmonary vasculature is a rare. We report a case of chronic pulmonary thromboembolism (PTE) secondary to cement embolization after kyphoplasty. CASE PRESENTATION: A 80-year-old female with past medical history significant for osteoporosis was referred by primary care physician to pulmonary clinic due to dyspnea on exertion for last 4 years. Her vitals were stable, with saturation of 95% at rest which dropped down to 89% while climbing stairs. Physical examination was non-significant. EKG showed sinus tachycardia. Arterial blood gas was normal with no acid base imbalance. Lateral chest X ray showed hyperdense lesion in L2 vertebra. The recent chest computed tomography angiogram (CTA) revealed hyperdense opacities in bilateral distal pulmonary arteries. Previous CTA also revealed similar filling defects. Hence, she was diagnosed with chronic pulmonary thromboembolism (PTE) with unknown etiology. She gave history of kyphoplasty 4 years back after vertebra fracture. She developed dyspnea after the procedure and was treated with coumadin for total of 6 months for presumptive pulmonary embolism. She continued to have dyspnea on exertion despite initial treatment with coumadin. Diagnosis of pulmonary cement embolism (PCE) leading to chronic thromboembolism was entertained due to history of kyphoplasty preceding dyspnea in the past. Hence, this condition remained undiagnosed and existed in our patient for long time. We offered her lifelong anticoagulation but she declined. DISCUSSION: Chronic PTE secondary to foreign bodies are very rare and usually missed. To the best of our knowledge, pulmonary thromboembolism secondary implantable devices and fractured venous catheter have been described but cement embolism has never been described as etiology for chronic PTE. Detailed history of kyphoplasty in the past and its correlation with dyspnea is key for the diagnosis of PCE as etiology for chronic thromboembolism. Asymptomatic PCE requires close monitoring but symptomatic or central PCE needs initial heparinization followed by coumadin for 6 month. Role of life long anticoagulation in case of persistent symptoms is not clear. CONCLUSIONS: PCE secondary to kyphoplasty can be one of the rare etiology for chronic PTE leading to pulmonary hypertension. Physicians should be aware that detailed history and review of radiology from the past are keys for this rare diagnosis