Authors: Kume H et al.
Cureus, 18(1): e101514, January 2026 DOI: 10.7759/cureus.101514
Summary
This case report describes the successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as rescue therapy for catastrophic Grade 3 bone cement implantation syndrome (BCIS) during total hip arthroplasty in an 80-year-old woman with moderate-to-severe aortic valve stenosis and moderate pulmonary hypertension. The authors present a rare survival with full neurological recovery following intraoperative cardiopulmonary collapse and cardiac arrest, a scenario traditionally associated with extremely high mortality.
Five minutes after bone cement implantation, the patient developed an abrupt fall in end-tidal CO₂, profound hypotension, and loss of arterial pulse pressure progressing to ventricular fibrillation and cardiac arrest. Despite aggressive vasopressor therapy and conventional cardiopulmonary resuscitation, hemodynamic stability could not be restored. Transesophageal echocardiography demonstrated acute right ventricular dilation and failure without evidence of thrombotic pulmonary embolism, consistent with severe BCIS physiology rather than mechanical obstruction.
Within approximately 30 minutes of cardiac arrest onset, VA-ECMO was initiated via a femoral approach, resulting in immediate hemodynamic stabilization. Subsequent imaging ruled out pulmonary embolism but demonstrated extrusion of bone cement beyond the medullary cavity, supporting a mechanism of pulmonary microembolization with acute pulmonary vascular resistance elevation. Adjunctive support with intra-aortic balloon pump and inhaled nitric oxide was used to offload the right ventricle and optimize pulmonary circulation.
The patient was successfully weaned from VA-ECMO on postoperative day 9 and from all advanced cardiopulmonary support thereafter, with gradual neurologic and functional recovery. She was discharged from the ICU on day 23 and from the hospital on day 52 without cognitive or neurological deficits.
The authors emphasize that rapid recognition of BCIS, differentiation from thrombotic pulmonary embolism, and immediate access to extracorporeal cardiopulmonary resuscitation were central to survival. Pre-existing right-sided cardiac vulnerability from aortic stenosis and pulmonary hypertension likely amplified the hemodynamic collapse once pulmonary vascular resistance acutely increased.
Key Points
• Grade 3 BCIS can cause sudden cardiac arrest with mortality approaching 90%
• Acute right ventricular failure, not thrombotic embolism, is the dominant mechanism
• VA-ECMO can provide lifesaving circulatory support when conventional resuscitation fails
• Early ECMO initiation with short low-flow duration is critical for neurologic preservation
• High-risk patients benefit from preoperative multidisciplinary planning and ECMO readiness
What You Should Know
For anesthesiologists, this case reinforces that BCIS should be anticipated in elderly orthopedic patients with pulmonary hypertension or fixed cardiac outflow obstruction. A sudden drop in EtCO₂ and refractory hypotension immediately after cementation should trigger suspicion for BCIS rather than assuming thrombotic pulmonary embolism alone. In centers with ECMO capability, early activation of extracorporeal cardiopulmonary resuscitation may be the decisive factor between death and full recovery in catastrophic Grade 3 BCIS.
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