Mechanical Thrombectomy of a Vertebroplasty-Related Pulmonary Cement Embolus

Abstract

Introduction

This is a case presentation of a 62-year-old woman who presents for new-onset dyspnea and chest pain after receiving an L4 vertebroplasty 3 months ago.

Results

Noncontrast computed tomography revealed a new linear hyperdense foreign body in the left pulmonary artery. Interventional radiology was consulted and performed a pulmonary angiogram, confirming a linear radiopaque foreign body consistent with polymethylmethacrylate bone cement.

Discussion

Following cement augmentation procedures, providers should consider diagnosis of pulmonary cement embolus if patients present with new cardiopulmonary symptoms. Although pulmonary cement embolism is a rare complication, it may present weeks to months after vertebroplasty and has the chance to be fatal.

Conclusion

Catheter-directed suction thrombectomy should be considered as an effective treatment method for polymethylmethacrylate bone cement embolism, a rare complication of vertebroplasty and kyphoplasty procedures.

Keywords

thrombectomy - cement embolism - interventional radiology

Case Presentation

This is a case report of a patient diagnosed with pulmonary cement embolism (PCE) treated with suction thrombectomy. Most PCEs are asymptomatic, but treatment is recommended in cases of symptomatic PCE, although there are currently no universal guidelines for the management of PCE. Embolectomy can be performed via interventional radiology (IR) catheterization; however, some patients may require sternotomy and placement on bypass to remove the emboli.[1] [2] In some patient cases, medical management was preferred, and the patient was placed on anticoagulation therapy. Most physicians will follow protocols for thrombotic pulmonary emboli and will prescribe 3 to 6 months of anticoagulation therapy, either alone or in conjunction with an embolectomy.[1] [2] [3] Studies have found that polymethylmethacrylate (PMMA) is not prothrombotic in vitro; however, there are mixed case findings of the removed PMMA embolus having an associated thrombus attached.[1] [4] The following sections describe the case in detail.

A 62-year-old woman with a history of L4 fracture treated by vertebroplasty at an outside facility 3 months prior presented with a syncopal episode, new-onset dyspnea at rest, and chest pain. She had a background of nonalcoholic steatohepatitis cirrhosis, coronary artery disease, persistent right pleural effusion, and hypothyroidism. Her relevant physical examination included decreased right lung breath sounds, in keeping with her known pleural effusion.

Imaging Findings

Noncontrast computed tomography (CT) of the chest, abdomen, and pelvis revealed a new linear hyperdense foreign body measuring approximately 5.5 cm within the left pulmonary artery ([Fig. 1]). Comparison with prior imaging showed a segment of vertebral cement previously extending into the inferior vena cava (IVC) that was now shortened, suggesting that this fragment had dislodged and embolized ([Fig. 2]). CT pulmonary angiography confirmed the foreign body within the left pulmonary artery but did not demonstrate acute or chronic thromboemboli. The patient's liver imaging was consistent with cirrhosis and minimal ascites, but no other pertinent findings were noted.

Fig. 1 Noncontrast CT of the chest showing a linear, high-attenuation foreign body (5.5 cm) lodged within the left pulmonary artery. CT, computed tomography.

Fig. 2 Comparison of coronal CT images obtained 3 months apart. The older lumbar spine CT (A) shows vertebral cement extending into the inferior vena cava (IVC). The recent abdominal CT (B) demonstrates a shortened cement column, suggesting that a portion has fractured and embolized distally. CT, computed tomography.

Intervention and Outcome

IR performed a pulmonary angiogram, confirming a linear radiopaque foreign body consistent with PMMA bone cement ([Fig. 3]). Access was obtained via the right femoral vein. The left pulmonary artery was selected, and pulmonary arterial pressure was obtained, 31/14 mmHg. Using an 18 French DrySeal sheath and a 16 French Penumbra suction thrombectomy device, the foreign body was successfully retrieved intact ([Fig. 4]). Post-thrombectomy angiogram demonstrated no remaining foreign body or other embolus ([Fig. 5]). Pulmonary arterial pressure decreased to 28/6 mmHg. The patient tolerated the procedure well, with improvement in resting oxygenation. She developed mild contrast-induced acute kidney injury that resolved with intravenous fluids. Clinical status was improved as the patient returned to baseline oxygenation status with resolution of symptoms, leading to discharge. The specimen was confirmed to be PMMA bone cement on gross examination ([Fig. 6]).

Fig. 3 Fluoroscopic image demonstrating the radiopaque foreign body in the left pulmonary arterial vasculature.

Fig. 4 Angiographic image illustrating advancement of the 16 French catheter over the foreign body.

Fig. 5 Post-suction thrombectomy fluoroscopic image demonstrating successful retrieval of the foreign body.

Fig. 6 Gross specimen of the retrieved cement fragment. The fragment is slender, tan in color, and measures 5.6 × 0.3 × 0.1 cm.

Discussion

PMMA cement extravasation and subsequent pulmonary embolization are uncommon but recognized complications of vertebroplasty and kyphoplasty procedures. Cement may migrate through perivertebral veins into the IVC and eventually lodge in the pulmonary circulation. Although many such emboli are asymptomatic and discovered incidentally, symptomatic presentations can mimic traditional pulmonary embolism and manifest as dyspnea or chest discomfort. High-attenuation cement fragments are easily identified on CT as linear hyperdense foreign bodies.[4] [5] [6] [7] Pulmonary embolism complications from vertebroplasty typically appear weeks to months after the procedure but some cases have been reported even years after surgery.[8] [9]

Management strategies vary depending on symptom severity, embolus size, and location.[1] [3] [5] [10] While most patients improve with less invasive interventions, rare cases of massive cement embolization have required open surgical approaches, including pulmonary wedge resection, to address infarction and persistent cardiopulmonary compromise.[7] Options range from close observation and anticoagulation to catheter-based embolectomy or open surgical retrieval. The patient was symptomatic with acute symptoms of chest pain, dyspnea, and syncope, leading to our decision to perform an intervention. Thrombectomy was to provide prompt blood flow restoration and quickly reduce symptoms. It should be preferred over anticoagulation in patients with a higher risk of major bleeding and those with PCE causing right ventricular strain or hemodynamic instability. In this patient, catheter-directed suction thrombectomy successfully removed the cement fragment without complications and resulted in clinical improvement. This procedure has demonstrated prior success in the literature and should be recommended as a feasible treatment option for patients presenting with pulmonary cement embolization.[11] While standardized guidelines for surveillance or management after vertebroplasty do not currently exist, clinicians should consider this diagnosis in patients presenting with new cardiopulmonary symptoms following cement augmentation procedures.[1] [4] [5] [7] [10]

Conflict of Interest

None declared.

Acknowledgements

None.

Ethical Statement

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• This material is the authors' own original work, which has not been previously published elsewhere.

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Date: 05/13/2025

• References

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Publication History

Article published online:
27 January 2026