DOI: 10.31038/JCCP.2026913

 

An 86-year-old man presented to his cardiologist for regular follow up with chest pain and exertional intolerance with tachycardia and palpitations. The patient had further medical history of paroxysmal atrial fibrillation, chronic back pain with cement vertebroplasty, ischaemic heart disease with previous multivessel coronary stenting, hypertension, hypercholesterolaemia, type two diabetes mellitus, stage four diabetic kidney disease and previous upper GI bleed whilst on dual antiplatelets. His medications were apixaban 2.5 mg BD, metoprolol 25 mg BD, digoxin 62.5 mcg daily, irbesartan 300 mg daily, lercanidipine 10 mg daily, atorvastatin 40 mg daily, dapagliflozin 10 mg daily, metformin 1 g daily and pantoprazole 40 mg daily.

ECG showed atrial fibrillation with a heart rate of 57 bpm and no ischaemic changes. Subsequent Holter monitor showed atrial fibrillation throughout with a minimum heart rate of 41 and maximum of 141. Transthoracic echocardiogram showed normal left ventricular size and function with stable mild valvular disease.

The patient described his symptoms as being like a previous presentation which led to a diagnosis of obstructive left main coronary artery disease. The patient underwent invasive coronary angiography which illustrated only moderate non obstructive coronary artery disease with patent stents. There was the unexpected finding of radio-opaque masses in the right atrial appendage and the right ventricle. This was associated with new T12 cement vertebroplasty (Figure 1).

Figure 1: Coronary angiogram showing two radio-opaque masses in the right atrial appendage and the right ventricle.

Upon review of previous imaging, the radio opaque masses were not present on chest X-rays from prior to vertebroplasty but appeared on X-ray following vertebroplasty. A non-contrast CT chest confirmed the presence of high attenuation material in the right atrial appendage (Figure 2) and inferior right ventricle (Figure 3) and bone cement in the thoracic vertebrae that had extravasated to the region of the paravertebral venous plexus (Figure 4). This was consistent with cardiac embolism of vertebral bone cement.

Figure 2: Axial view of CT chest showing high attenuation material in the right atrial appendage.

Figure 3: Sagittal view of CT chest showing high attenuation material in the inferior right ventricle.

Figure 4: Sagittal view of CT chest showing cement in T12 vertebral body, extravasating into the paravertebral region.

Retrospective review of previous transthoracic echocardiogram showed a calcified area noted in the right ventricle near the moderator band and another in the right atrial appendage (Figure 5).

Figure 5: Transthoracic echocardiogram illustrating a bright, calcified area in the right ventricle.

The case was discussed at a cardiology multidisciplinary team meeting regarding invasive or medical management due to the risk of cement embolism erosion. The consensus was to manage the case conservatively with anticoagulation to prevent thrombus formation on the cement as the patient had not had any complications of the embolism to date and due to his advanced age and comorbidities. The patient’s apixaban was increased to 5 mg BD and his symptoms remained stable.

Discussion

Percutaneous vertebroplasty is used to treat osteoporotic fractures to reduce pain and provide stability to the spine [1]. The procedure involves injecting polymethylmethacrylate (PMMA) cement into the diseased vertebrae and the main risks are associated with the leakage of cement into the surrounding structures. With absorption into the iliolumbar and epidural veins, the cement can gain access to the central circulation.

The rate of extravasation into central veins during this procedure is estimated at 23% however usually particles of cement are small, and the patient remains asymptomatic. Symptomatic intracardiac embolism is estimated to occur in only 0.3% of cases [2]. Sequelae of embolism can involve arrhythmia, valve dysfunction, pulmonary embolism and rarely cardiac perforation resulting in tamponade.

If the suspicion for intracardiac cement embolism (ICE) is high, CT chest and TTE should be performed to confirm the diagnosis, location of the embolism and to assess for complications. The bone cement is high attenuation and has been described as 373-1600 Hounsfield units when embolised to the heart [3]. However as seen in this case other modalities including chest X ray and fluoroscopy can make the diagnosis.

Risk factors for embolism include higher number of segments, injection into the thoracic vertebrae, tumour related fractures, higher amounts of bone cement used and lower viscosity cement [4].

Prevention of ICE includes the use of high viscosity cement to reduce extravasation, avoiding over pressurisation and injecting under fluoroscopy to assess for embolization during the procedure [5].

Recommendation on management of ICE depends on the patient’s status. In asymptomatic patients, observation without intervention is most appropriate. Small cement emboli routinely do not cause symptoms so routine post procedural imagining is not recommended.

Symptomatic patients may require intervention. Patients with cardiac rupture and tamponade require urgent surgical intervention to remove the fragment and repair the myocardial defect. There have been case reports of percutaneous removal of fragments that are amenable to do so that are either high risk of causing cardiac rupture or impinging on the tricuspid valve apparatus [5].

References

1. Jay B, Ahn SH (2013) Vertebroplasty. Semin Intervent Radiol. [crossref]
2. Kim YJ, Lee JW, Park KW, Yeom JS, Jeong HS, Park JM, Kang HS (2009) Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures incidence characteristics and risk factors. Radiology. [crossref]
3. Oshinsky C, Bhavani S, Funaki A (2018) Cement cardiac embolism following kyphoplasty noted on thoracic imaging. Radiol Case Rep. [crossref]
4. Wang L, Lu M, Zhang X, Zhao Z, Li X, Liu T, Xu L, Yu S (2023) Risk factors for pulmonary cement embolism after percutaneous vertebroplasty and radiofrequency ablation for spinal metastases. Front Oncol. [crossref]
5. Zhao Z, Wang R, Gao L et al. (2024) Pulmonary embolism and intracardiac foreign bodies caused by bone cement leakage a case report and literature review. J Cardiothorac Surg. [crossref]

DOI: 10.31038/JCCP.2026912

 

Coronary artery bypass grafting (CABG) remains the most durable revascularisation strategy for patients with multivessel coronary artery disease, with established long-term survival advantages over percutaneous coronary intervention in complex anatomical disease [1,2]. Yet despite decades of surgical refinement, one of the most consequential intraoperative decisions, conduit selection, remains insufficiently resolved by high-quality prospective evidence. The Total Arterial (TA) Trial, (clinical trial registry: ACTRN12623000864628) funded by the Australian Medical Research Future Fund, represents a serious and timely effort to address that gap.

The central question is simple: does the complete exclusion of saphenous vein grafts (SVGs) in favour of total arterial revascularisation (TAR) translate into superior graft patency and better clinical outcomes? The biological basis for expecting so is well-established. SVGs are anatomically and haemodynamically mismatched for the arterial circulation – subjected to pressures they were not designed to withstand – and the consequences are of reasonably predictable and progressive graft failure. Approximately 40–50% of SVGs occlude within 10 years, contributing significantly to postoperative myocardial infarction, repeat revascularisation, and premature mortality [3,4]. Arterial conduits appear to behave differently. Whether internal mammary arteries or radial arteries, they exhibit resistance to progressive atherosclerosis, adaptive remodelling, and durable angiographic patency over decades of follow-up [5,6]. Large registry analyses, including data from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries, have consistently associated TAR with a survival advantage [7,8].

The key question is whether this survival signal reflects the true biological superiority of arterial conduits or is substantially confounded by patient selection and operator expertise. Patients who receive TAR tend to be younger, less comorbid, and operated on by surgeons with higher procedural volumes. Observational analyses, however carefully risk-adjusted, cannot fully account for these confounders. Randomised allocation remains the only mechanism to isolate conduit biology from surgical selection – and prior trials have not achieved this adequately.

The Arterial Revascularisation Trial (ART) was undermined by a crossover rate exceeding 10% post-randomisation, diluting the treatment contrast and complicating interpretation of its insignificant result at 10 years [9]. Whether ART failed to show a benefit because none exists, or because insufficient patients received the assigned treatment, remains unresolved. However, it is also noteworthy that both arms could have received SVG. The ongoing ROMA trial, while more rigorously designed than the ART trial, addresses a related but distinct question: the number of arterial grafts, rather than the complete elimination of venous conduits [10]. Both arms of ROMA permit SVG use, which cannot therefore directly address whether abolishing venous grafting entirely – the strategy with the most consistent observational support, could improve survival.

The TA Trial is deliberately designed to address these limitations. By defining its intervention as zero SVGs versus at least one SVG, it isolates the specific variable that observational data most consistently associates with long-term outcome differences [7,11]. For clarity, unlike ART and ROMA, the focus of the investigation relates not to the arterial conduit use – but rather to the venous conduit use. The pragmatic surgical design –imposing no restrictions on conduit type, graft configuration, or reconstruction technique within the TAR arm – reflects clinical equipoise and preserves generalisability. This acknowledges that TAR is not a single operation but a surgical philosophy, executable through multiple technically sound configurations [12,13].

Equally important is the trial’s approach to protocol compliance. ART established that investigator non-compliance is a practical threat to trial validity, and not a theoretical one. The TA Trial approach mandates logbook review to confirm surgeon competence in TAR, requiring preoperative written confirmation of equipoise for every randomised patient, and instituting individual investigator follow-up after each protocol breach. These are the structural safeguards upon which the trial’s interpretability depends.

Selecting perfect graft patency as the primary endpoint at 24 months is scientifically well-justified. Simple patency captures graft survival but not graft health; a vein graft that is open but internally diseased will ultimately fail, and simple patency misses this trajectory. Perfect patency – a patent conduit with a smooth, regular lumen free of atherosclerotic change – provides an angiographic surrogate for long-term conduit durability validated against clinical outcomes.6 Assessment by CT coronary angiography with sensitivity and specificity exceeding 98% [14] allows non-invasive, reproducible assessment across all 18 sites. The additional CTCA at 3 months is a noteworthy design strength, offering a structured examination of early competitive flow effects on arterial graft function, a phenomenon that likely explains a proportion of early graft failures but remains poorly characterised prospectively [15].

Australia is uniquely positioned to conduct this trial. TAR utilisation rates across Australian centres substantially exceed those reported in North America and Europe [7], ensuring a sufficient pool of surgeons with established expertise in both TAR and non-TAR techniques. This mitigates a key methodological concern: differential technical proficiency across study arms could confound the treatment effect. The trial’s findings will therefore reflect outcomes achievable within a mature surgical environment, strengthening their external validity and translational relevance.

Conclusion

The TA Trial is the first prospective, randomised investigation designed to directly test whether complete elimination of venous conduits from CABG translates into measurable improvements in graft integrity and, through its comprehensive secondary outcome framework, patient survival and quality of life. If it confirms the observational literature, its implications for surgical practice and guideline development good be substantial and impactful. The cardiac surgery community has waited a long time for this evidence.

Authorship and Contributions

Justin Ren, writing and conceptualization of the manuscript. Alistair Royse, writing and conceptualization of the manuscript. Colin Royse, co-author and reviewer.

Acknowledgements

The author has acknowledged that this summary commentary is written on behalf of the TA Trial Steering Committee.

Conflicts

This manuscript has not been funded. The authors declare that they are the architects of the TA Trial study design and have written multiple supporting analyses for this trial.

Keywords

TA Trial, Total arterial revascularisation, TAR, Graft angiography

References

1. Neumann FJ, Sousa-Uva M, Ahlsson A et al. (2019) 2018 ESC/EACTS Guidelines on myocardial Eur Heart J. [crossref]
2. Farkouh ME, Domanski M, Dangas GD et (2019) Long-term survival following multivessel revascularization in patients with diabetes the FREEDOM Follow-On study. J Am Coll Cardiol. [crossref]
3. Caliskan E, de Souza DR, Böning A et al. (2020) Saphenous vein grafts in contemporary coronary artery bypass graft Nat Rev Cardiol. [crossref]
4. Goldman S, Zadina K, Moritz T et (2004) Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol. [crossref]
5. Ren J, Royse C, Siderakis C et (2024) Long-term observational angiographic patency and perfect patency of radial artery compared with saphenous vein or internal mammary artery in coronary bypass surgery. J Thorac Cardiovasc Surg. [crossref]
6. Royse AG, Brennan AP, Ou-Young J et al. (2018) 21-year survival of left internal mammary artery–radial artery–Y J Am Coll Cardiol. [crossref]
7. Royse A, Ren J, Royse C et (2022) Coronary artery bypass surgery without saphenous vein grafting JACC Review Topic of the Week. J Am Coll Cardiol. [crossref]
8. Rocha RV, Tam DY, Karkhanis R et (2020) Long-term outcomes associated with total arterial revascularization vs non-total arterial revascularization. JAMA Cardiol. [crossref]
9. Taggart DP, Benedetto U, Gerry S et (2019) Bilateral versus single internal-thoracic-artery grafts at 10 years. N Engl J Med. [crossref]
10. Gaudino M, Alexander JH, Bakaeen FG et al. (2017) Randomized comparison of the clinical outcome of single versus multiple arterial grafts the ROMA trial—rationale and study Eur J Cardiothorac Surg. [crossref]
11. Royse A, Pawanis Z, Canty D et (2018) The effect on survival from the use of a saphenous vein graft during coronary bypass surgery a large cohort study. Eur J Cardiothorac Surg. [crossref]
12. Royse AG, Bellomo R, Royse CF et al. (2021) Radial artery vs bilateral mammary composite Y coronary artery grafting 15-year outcomes. Ann Thorac Surg. [crossref]
13. Ren J, Tian DH, Gaudino M et (2023) Survival benefit of multiple arterial revascularization with and without supplementary saphenous vein graft. J Am Heart Assoc. [crossref]
14. Barbero U, Iannaccone M, d’Ascenzo F et (2016) 64 slice-coronary computed tomography sensitivity and specificity in the evaluation of coronary artery bypass graft stenosis a meta-analysis. Int J Cardiol. [crossref]
15. Glineur D, D’hoore W, de Kerchove L et (2011) Angiographic predictors of 3-year patency of bypass grafts implanted on the right coronary artery system a prospective randomized comparison of gastroepiploic artery saphenous vein and right internal thoracic artery grafts. J Thorac Cardiovasc Surg. [crossref]