An Incidental Finding of Pulmonary Cement Embolism Four Weeks After Vertebroplasty in a 50-Year-Old Man with Multiple Myeloma.

BACKGROUND Vertebroplasty is a minimally invasive radiological procedure that involves injection of cement to stabilize the fractured vertebra. It has also been increasingly used to relieve pain in patients with bone-incorporated malignancies. The most frequently encountered complication of this procedure is inadvertent cement leakage, which has the potential to embolize. This report presents an incidental finding of cement embolism during fluoroscopy for a peripherally inserted central catheter (PICC) line 4 weeks after vertebroplasty in a 50-year-old man with multiple myeloma. CASE REPORT Our report details the case of a 50-year-old man who presented for progressive sciatic nerve pain and was found on imaging to have an L3 fracture, spinal stenosis, lumbar spinal spondylosis, and diffusely decreased bone density, eventually diagnosed with multiple myeloma. For symptomatic relief and vertebrae stabilization, he underwent a CT-guided fluoroscopic vertebroplasty procedure. Four weeks later, during fluoroscopy for a PICC, he was incidentally found to have radiopaque opacities within the pulmonary arteries. He was diagnosed with a pulmonary embolism due to transvertebral cement leakage from his vertebroplasty. Given the central nature of his embolism, he was treated with anticoagulation and closely monitored. Throughout the treatment period, he remained asymptomatic with normal vital signs and NT-brain natriuretic peptide. CONCLUSIONS This report highlights the association between vertebroplasty and pulmonary cement embolism (PCE), the potential for late detection upon chest imaging even weeks after vertebroplasty, and suggests that some patients with PCE may need therapeutic anticoagulation.

Evaluation and management of chronic pulmonary thromboembolic disease.

Pulmonary embolism (PE) is common and the majority of patients survive the acute event. Survivors are at increased risk for adverse outcomes, including persistent thrombi, recurrent embolism, chronic thromboembolic pulmonary hypertension (CTEPH), and death. Anticoagulation protects against recurrence, which has a high mortality rate. The recommended duration of anticoagulation for patients with reversible PE risk factors is 3 months. For patients with idiopathic PE or persistent risk factors, extended duration of anticoagulation is preferred, balanced with an individual patient's risk of hemorrhage, which in itself is a major cause of morbidity and mortality. Among patients with malignancy who develop venous thromboembolism (VTE), low-molecular-weight heparin is preferred over oral vitamin K antagonists in the first 6 months. Thereafter, anticoagulation should be continued indefinitely with either low-molecular-weight heparin or oral vitamin K antagonists. Inferior vena cava filters are not routinely recommended and should only be used in patients who have a contraindication to anticoagulation. Patients who have had VTE and with persistent or recurrent dyspnea should be evaluated for recurrence of VTE or development of CTEPH. Patients with recurrent VTE should be anticoagulated indefinitely. Routine screening for CTEPH in asymptomatic patients is not recommended. Echocardiography often provides the first indication of the presence of pulmonary hypertension. Once presence of CTEPH is established by right-sided heart catheterization and perfusion imaging (ie, ventilation/perfusion scintigraphy, computed tomography angiography, or pulmonary angiography), patients should be referred early to a center with expertise, as it is potentially surgically curable by pulmonary endarterectomy. Those who are deemed inoperable after being evaluated may gain symptomatic benefit from drugs approved for idiopathic pulmonary arterial hypertension. Lung transplantation may also be an option for patients who are not candidates for pulmonary endarterectomy.

Complete tracheal duplication in an adult with thoracic aortic coarctation.

Partial and complete duplication of the trachea have previously been reported as rare causes of respiratory distress in children. We report a case of complete tracheal duplication detected incidentally in an adult during a computed tomography angiogram of the heart performed as part of an evaluation for coarctation of the aorta.