Off-Pump Methacrylate Cement Pulmonary Embolectomy

Methacrylate is polymer used as a bone cement in orthopedic procedures that can rarely embolize, resulting atrial perforation and pulmonary artery occlusion. Retrieval of emboli typically requires cardiopulmonary bypass deep hypothermic circulatory arrest. In this report, we describe the off-pump removal massive left methacrylate embolus using surface ultrasound localization, partial cross-clamping main artery, snaring venous return. commonly such kyphoplasty. Prior to hardening, travel through systemic return, where it solidifies become embolus. The frequency embolism unknown, but at least 30 patients have been identified with one third reporting symptoms 1 attributable death.1Krueger A. Bliemel C. Zettl R. Ruchholtz S. Management after percutaneous vertebroplasty kyphoplasty: systematic review literature.Eur Spine J. 2009; 18: 1257-1265Crossref PubMed Scopus (228) Google Scholar true incidence may be much higher, given vague clinical number asymptomatic emboli. Large occlude or erode vessel wall leading perforation.2Weininger G. Elefteriades J.A. Intracardiac embolism.N Engl J Med. 2021; 385: e49Crossref (3) Scholar,3Swojanowsky P. Brinkmeier-Theofanopoulou M. Schmitt Mehlhorn U. A rare cause pericardial effusion due intracardiac embolism.Eur Heart 2018; 39: 3001Crossref (4) Depending on location embolus, embolectomy case reported below, by localizing ultrasound, clamping trunk, veins, were able perform an embolectomy. 36-year-old woman anxiety, herniated disc (L3-L4), lumbar stenosis (L4-S1) underwent kyphoplasty polymethylmethacrylate medical 2020 for chronic lower back pain. Postoperatively, she developed progressive dyspnea chest Physical exam laboratory workup unremarkable. Outpatient radiography suggested foreign body computed tomography arteriogram confirmed presence within extending basilar trunk lobe (Figure 1). Transthoracic echocardiogram revealed normal right ventricular cavity systolic function. However, concern progression risk erosion vessel, was recommended. Pulmonary performed hemiclamshell incision (partial sternotomy teeing off fourth intercostal space). This approach provided access proximal distal veins. It also central emergent bypass. Intraoperative transesophageal echocardiography (TEE) assess global function before during trunk. Additionally, TEE along placed confirm directed 2). Further vascular isolation achieved placement snares around superior inferior clamp occluded all flow partially artery. patient tolerated veins without significant hemodynamic compromise unnecessary. Right monitored throughout TEE. longitudinal made intrapericardial adherent endothelium peeled arterial several individual pieces 3). morphology removed correlated images obtained arteriogram, TEE, closed primarily, no residual visualized extubated operating room discharged home postoperative day 4. follow up, resolution denied any shortness breath.Figure 3Methacrylate piecemeal from artery.View Image Figure ViewerDownload Hi-res image Download (PPT) potentially devastating complication other common procedures. thought occur when injected remains too fluid under pressure. Surgery primary treatment only way ensure complete Three 6 months anticoagulation alterative operative management.1Krueger Anticoagulation prevent thrombus forming Over becomes endothelialized propagation minimized. We did note our report appeared incorporated into wall. unless removed, associated initial are unlikely resolve, Given dense attachments catheter-based techniques would catastrophic perforation. Importantly, instrumental extent emboli, assessing patency supporting mid-esophageal ascending aorta short axis view ° omniplane. probe rotated left, providing embolism. utilized intraoperatively single lung ventilation, clamping, Likewise, key ensuring safe clamping. While intraoperative epiaortic ultrasonography has described identification plaque aorta, represents unique application ultrasound.4Glas K.E. Swaminathan Reeves S.T. et al.Guidelines performance comprehensive ultrasonographic examination: recommendations American Society Echocardiography Cardiovascular Anesthesiologists; endorsed Thoracic Surgeons.J Am Soc Echocardiogr. 2007; 20: 1227-1235Abstract Full Text PDF (61) Despite success, best practice maintain exposure rapid peripheral cannulation should need arise. case, above imaging ensured cross