Gelfoam Embolization Technique to Prevent Bone Cement Leakage during Percutaneous Vertebroplasty: Comparative Study of Gelfoam only vs. Gelfoam with Venography

Let us settle the controversy-gelfoam is a safe intravascular embolic agent

OBJECTIVES

A 2021 safety alert restricted endovascular gelfoam use in Australia and resulted in an embargo on gelfoam sales to Interventional Radiology departments. This study aimed to show that gelfoam is safe in a population of trauma patients with pelvic injury, and discuss the basis of the recent controversies.

METHODS

Retrospective cohort study was conducted between 1 January 2010 and 21 May 2021 for the patients who underwent gelfoam embolization for pelvic arterial haemorrhage. Primary outcome was the rate of adverse events related to intravascular gelfoam administration.

RESULTS

Inclusion criteria met in 50 patients, comprising 58% males median age 59.9 years, and median injury severity score 31. There were 0 complications related to gelfoam use and 100% technical success. Thirty-five patients (70%) received a non-targeted embolization approach. All-cause mortality was observed in 5 patients (10%), unrelated to gelfoam.

CONCLUSIONS

Gelfoam is a safe and effective embolic agent in pelvic trauma. Patients are in urgent need of universal on-label registration of endovascular gelfoam products, as it is life-saving in major haemorrhage after trauma.

ADVANCES IN KNOWLEDGE

Endovascular gelfoam is mandatory for a high-quality trauma service, and this study shows that it is safe to use intentionally in the endovascular space. Companies should work with interventional radiologists, sharing and collaborating to ensure positive outcomes for patients.

Hemostatic Agents in Orthopedic Surgery

Controlling blood loss is a crucial aspect of orthopedic surgery. Hemostatic agents can be used intraoperatively in combination with antifibrinolytics as part of an overall strategy to limit blood loss. Several new hemostatic agents have recently come to the market designed specifically for vascular surgery but have found uses in other surgical fields, including orthopedics. This article reviews the mechanisms of action and best uses of various mechanical hemostats, active hemostats, flowable hemostats, and fibrin sealants for achieving hemostasis in orthopedic surgery. Mechanical and active hemostats have been reported to successfully decrease blood loss from cancellous bone, capillaries, and venules. Flowable hemostats are generally favorable for use in small spaces where the swelling capabilities of mechanical and active hemostats can be detrimental to surrounding structures. Sealants are best used for closing defects in tissues.

A Nomogram to Predict Intra-Spinal Canal Cement Leakage Among Elderly Patients with Spine Metastases: An Internal-Validated Model

Purpose

This study aimed to assess the risk variables for predicting intra-spinal canal cement leakage, especially among elderly patients with spine metastases after being treated with percutaneous vertebroplasty (PVP). Furthermore, we proposed and validated a nomogram to stratify risks of intra-spinal canal cement leakage.

Methods

We retrospectively analyzed 163 elderly patients (age ≧65 years) with spine metastases who underwent PVP. Patients were randomly divided into a training cohort (n=100) and a validation cohort (n=63). The multivariate logistic regression analysis was used to screen potential risk variables in the training cohort. Significant risk variables were included in the nomogram, and the nomogram was developed according to the estimates of the each included variable. The predictive effectiveness of the nomogram was validated using discrimination and calibration performance.

Results

The overall prevalence of intra-spinal canal cement leakage was 9.82% (16/163). In the training cohort, female patients (14.71%, 5/34) showed a higher rate of intra-spinal canal cement leakage as compared with male patients (4.55%, 3/66). The nomogram consisted of sex, cortical osteolytic destruction in posterior wall, and load-bearing lines of spine. The nomogram had acceptable discrimination, with the area under the receiver operating characteristic (AUROC) of 0.75 in the training cohort, 0.64 in the validation cohort, and 0.69 in the entire cohort, and also showed favorable calibration based on the goodness-of-fit test. According to the nomogram, three risk groups were developed: the low risk group had an actual probability of 7.03%, the medium risk group was 11.54%, and high risk group was 44.44%. The difference between the three groups was significant (P ˂ 0.01).

Conclusion

Intra-spinal canal cement leakage after PVP is not scarce among elderly patients. We proposed and internally validated a nomogram that is capable of calculating the risk of intra-spinal canal cement leakage among elderly patients with spine metastases. Careful surgical plan should be conducted among patients with a high risk of developing intra-spinal canal cement leakage.

Cement venogram as a harbinger of methacrylate embolism after kyphoplasty: A case series

Vertebral compression fractures remain an important cause of pain and debility. Intractable pain may be approached with vertebral kyphoplasty. We herein present a case of symptomatic pulmonary cement embolism following kyphoplasty. Discovery of a paravertebral cement venogram at the time of this procedure prompted a case series review of our institutional experience with kyphoplasty. We found that cement embolization, whether symptomatic or discovered incidentally, was universally associated with a cement venogram at the site of vertebroplasty. We propose that a cement venogram be viewed as a harbinger of cement pulmonary embolism and this possibility be considered in patients with an existing intracardiac shunt or who present with new respiratory symptoms soon after kyphoplasty.