Don't Break My Heart with Stone
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Dear SCCT Member:


As you know, the SCCT is the only professional medical membership organization dedicated to ensuring patient access to the appropriate use of cardiovascular CT. The SCCT Board of Directors thought that it would be beneficial to our members to create a Case of the Month series showcasing cardiac CTA in various clinical scenarios. this series will be spearheaded by the collective members of the SCCT FiRST committee. Please provide feedback or forward any questions to 


Don't Break My Heart with Stone: Role of Computed Tomography Angiography in the Assessment of Cement Emboli Secondary to Percutaneous Vertebroplasty


Gustavo Vazquez, MD *, Parag H. Joshi, MD, MHS ¥,

Jeffrey Hershey, MD ᴕ, James Kauten, MD, Chris Meduri, MD, Robi Goswami, MD,  Sarah Rinehart, MD, FACC, FSCCT ᴕ


*Global Institute for Research, LLC, Richmond, VA, ¥ Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, ᴕ Piedmont Heart Institute, Atlanta, GA



A 72 year old female with a medical history of mastectomy for breast cancer was complaining of severe debilitating lumbar back pain despite conservative therapy with narcotics and analgesics. A CT-PET scan confirmed the presence of multiple bone metastases including the vertebral bodies of C2, T1, L2, L3, L4, the left iliac wing and the proximal left femur. The patient was referred for bone tumor radio frequency ablation with computed tomography guidance and a percutaneous lumbar vertebroplasty with a bone biopsy. Fluoroscopy guided, radio frequency ablation was performed in the L2 vertebral body. A total of 5.5 mL of acrylic bone cement was injected into the left vertebral body. The bone cement stayed within the vertebral body extending through areas of radiofrequency ablation and the pathologic lesion (Figure 1). There were no apparent early complications and the patient was discharged home. Later, she developed intermittent atypical chest pain associated with dyspnea on exertion.

Figure 1. Under fluoroscopy guidance (A), a Dfine trocar was advanced from a posterior approach and into the left pedicle of the vertebral body L2 (B). After radiofrequency ablation, the bone cement delivery cannula was then deployed into the left vertebral body. A total of 5.5 mL of acrylic bone cement was injected (C). The bone cement stayed within the region of radiofrequency ablation as well as the pathologic lesion (D). However, some of the cement appears to traverse into an adjacent vein (yellow arrow).

A transesophageal echocardiogram demonstrated preserved right and left ventricular function, mild to moderate tricuspid insufficiency and mildly elevated right ventricular systolic pressure. An abnormal linear echo-density was noted in the right ventricle. The linear structure protruded into the mid interventricular septum towards the left ventricle without evidence of an interventricular shunt (Figure 2).

Gated computed tomography angiography (CTA) of the thorax confirmed the presence of multiple linear densities. The first hyper-dense structure, measuring over 5 cm in length, extended from the right atrium, through the tricuspid valve into the right ventricle, and crossed the interventricular septum, with its tip located in the left ventricle. The second linear structure, approximately 4 cm in length, was located within the right ventricle with its distal end located near the right ventricle apex. A third foreign structure was located within the pulmonary arterial system (Figure 3).

The patient was considered high risk for heart rupture, systemic embolization, acute stroke and sudden death. Her oncologist deemed that her survival would be greater than a year. Pre-operative invasive coronary angiography showed normal coronary arteries and confirmed the presence of three linear structures and a density in the middle lobe of the right lung (Figure 4).

The patient underwent cardiac surgery with removal of the foreign body located in the right ventricle, interventricular septum and left ventricle. This foreign body had impinged on the posterior leaflet of the tricuspid valve resulting in mild to moderate tricuspid regurgitation. The tip of the structure also had induced an abraded region on the surface of the right atrial wall. The second foreign body was removed from the right ventricular apex. Finally, primary closure of the interventricular septal defect was performed. The right lower lobe foreign bodies were left in place as risk of removal exceeded benefit (Figure 5). There were no surgical complications and patient was discharged home.

Figure 2. Trans-thoracic echocardiogram 4-chamber view demonstrated a linear echo-density (yellow arrow) located in the right ventricle which perforates the interventricular septum and traverses into the left ventricle (A). Trans-esophageal echocardiogram confirmed that the foreign body originates in the right atrium crosses the tricuspid valve (B, C) and extends into the right ventricle with subsequent protrusion through the interventricular septum into the left ventricle (D). RA: right atrium; RV: right ventricle; LV: left ventricle

Figure 3. Gated computed tomography angiography confirmed the three linear structures. The first linear structure is located in the right ventricular apex. The second linear density arises in the region of the tricuspid valve with penetration through the interventricular septum and into the left ventricle. The third hyper-dense structure is more irregular and is located in the lower branch of the right pulmonary artery (yellow arrows, A). There are densities located in the lower branch of the right pulmonary artery, which are irregular and conform to the course of the pulmonary artery (red circle, B). This likely represents early embolization of the cement when it was in semi-liquid form. Perforation of the interventricular septum is demonstrated in the four chamber view and short axis view (C, D). RA: right atrium; LA: left atrium; RV: right ventricle; LV: left ventricle; PA: pulmonary artery; Ao: Aorta

Figure 4. Left heart catheterization was performed (A). No angiographically significant disease was demonstrated in the right coronary artery (B), left circumflex, or left anterior descending coronary arteries (B, C). In the angiography views, there appear to be three linear structures (yellow arrows) and densities in the middle lobe of the right lung (red circles).

Figure 5. Cement emboli extracted from heart. Foreign body is demonstrated entering the septal region of the right ventricle (A). The foreign body is compressing the posterior leaflet of the tricuspid valve. Indentation of the posterior leaflet is visualized (B). The foreign body is visualized from the atrial view and extends through the closed tricuspid valve (C). Site of closure of opening in the inter-ventricular septum utilizing Prolene suture and Cor-Knot® (D). Another view demonstrating foreign body traversing through the tricuspid valve (E). There is an abraded region of the right atrial surface by the foreign body (F). 

Percutaneous vertebroplasty is frequently used in the treatment of vertebral body fractures due to vertebral body metastasis or multiple myeloma [1]. Cement leakage is the most frequent complication arising after percutaneous vertebroplasty and kyphoplasty [1,2].

Acrylic cement of polymethylmethacrylate injected into the vertebral body can leak into the paravertebral venous system and reach the pulmonary artery via the azygos vein leading to a cement pulmonary embolism [3].

To the best of our knowledge, this is the first description of a foreign body derived from cement embolism resulting in perforation of the interventricular septum.

In this particular case, CTA was essential in the complete anatomic evaluation of cardiac and extra cardiac structures. CTA confirmed the presence and locations of 3 linear foreign bodies and their associated complications, including penetration of the interventricular septum and pulmonary embolization. CTA should be one of the initial imaging modalities performed in symptomatic patients with history of prior percutaneous vertebroplasty.

1.- Mousavi P, Roth S, Finkelstein J, Cheung G, Whyne C (2003) Volumetric quantification of cement leakage following percutaneous vertebroplasty in metastatic and osteoporotic vertebrae. J Neurosurg 99:56-59.

2.- Phillips FM, Todd WF, Lieberman I, Campbell-Hupp M (2002) An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty. Spine 27:2173-2178. doi:10.1097/00007632-200210010-00018

3.- Krueger A, Bliemel C, Zettl R, Ruchholtz S. Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature. Eur Spine J 2009;18:1257-1265


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