A Limb-Saving Procedure for Treatment of Arterial Cement Embolism during Lumbar Percutaneous Vertebroplasty: A Case Report
The patient was a 46-year-old woman with a history of breast cancer 3 years earlier. She presented with a pathologic compression fracture in body and both pedicles of the third lumbar vertebra (L3), verified by bone scan and lumbar magnetic resonance imaging (MRI). The patient underwent PV with PMMA on July 27, 2009.\nA vertebral body biopsy prior to cement injection was done, and the procedure was subsequently completed uneventfully using the bilateral transpedicular approach guided by C-arm fluoroscopy.\nWithin the first hour post-procedural period, while the patient was in the recovery room, she complained of abdominal pain, which improved within minutes, followed by severe pain and numbness in the left leg. The left foot of the patient was found to be pale and cold with the sign of developing mottling and cyanosis from the knee level down. The calf muscles were also tender on examination. She had no detectable arterial pulses below her left knee by palpitation, which was confirmed by an emergency Doppler examination revealing the complete lack of blood flow in both dorsalis pedis and posterior tibial arteries.\nConsequently, the patient underwent the computed tomographic (CT) scan of the lower limbs and abdomen, which showed hyperdense foci (cement) in the anatomic site of the popliteal, anterior tibial, posterior tibial, and peroneal arteries as well as in the left L3 lumbar artery extending into the abdominal aorta situated above its bifurcation ().\nThe diagnosis of acute left leg ischemia due to the acute occlusion of the 3 infrapopliteal arteries by cement was considered. A loading dose of 300 mg Aspirin and 450 mg Clopidogrel was given, intravenous (IV) heparin was chosen as a foundation anticoagulant, and lower limb angiography was immediately performed with vascular access obtained in the right femoral artery. The angiogram revealed scattered opacity in the otherwise normal left iliac and superficial femoral arteries. The proximal portions of the popliteal arteries had also acceptable blood flow but thereafter a cement cast existed causing a poor run-off from the popliteal fossa distally ().\nAfter discussing the case with the vascular consultant, since there were diffuse and long vessel involvements and there were no distal targets for by-pass vascular surgery, we opted for transluminal angioplasty (PTA) of the infrapopliteal arteries. We used the crossover approach via the contralateral common femoral artery to access the infrapopliteal arteries. Multilevel intervention was performed through a long 6-F Shuttle sheath (Cook Medical), and total occlusions were traversed with 0.014-inch hydrophilic wires (Shinobi, Cordis, Miami, Florida).\nWe were able to dilate the lesions of the anterior tibial artery at its origin, proximal, and mid parts by utilizing a 2.5 mm × 120.0 mm Pacific Xtrime (Invatec, Rocandelle, BS, Italy) balloon, while the distal portions of this artery and the dorsalis pedis artery were repeatedly inflated with a 2.5 mm × 30 mm Sprinter balloon catheter (Medtronic, Inc., Minneapolis, Minnesota) (). Then in an effort to dilate the totally occluded posterior tibial artery at the bifurcation of tibioperoneal trunk, the balloon was attached to the cement lining in the artery wall, and part of its distal fragment remained in this vessel (). Finally, utilizing a 2.0 mm × 80.0 mm Amphirion Deep (Invatec, Rocandelle, BS, Italy), balloon, angioplasty was performed for the peroneal artery with good results. The final imaging showed an acceptable blood flow in the anterior tibial artery, and in the tibioperoneal artery (). Although finally the occluded parts of the dorsalis pedis and peroneal arteries did not respond to balloon dilation, the flow to the distal bed seemed to have been improved significantly mainly by the collaterals from the proximal and mid parts of the anterior tibial artery and the peroneal arteries. The overall time in the Catheter Laboratory was about 3 hours. The patient’s postoperative course was uncomplicated; the extremity tenderness and mottled skin were improved. An arterial duplex scan performed on postoperative day 5 showed normal velocities with mild stenosis in the1/3 distal portions of the anterior and posterior tibial arteries. Also, no flow was observed in the dorsalis pedis artery. She was discharged on postoperative day 10 on Clopidogrel (75 mg/day) and Aspirin (80 mg/day). A follow-up ultrasound 2 months later revealed an acceptable distal flow in the arteries of the affected limb, and the patient remained asymptomatic (except for a mild leg pain on exertion) at the 1-year follow-up examination.