Letter to the Editor Anuria due to acute bilateral renal vein occlusion after thrombolysis for pulmonary embolism Epaminondas Zakynthinos * , Evangelia Douka, Zoi Daniil, Kosmas Konstantinidis, Vassiliki Markaki, Spyros Zakynthinos Department of Critical Care and Pulmonary Services, University of Athens Medical School, ‘Evangelismos’ Hospital, 45-47 Ipsilantou st, 10675 Athens, Greece Received 25 December 2003; accepted 8 January 2004 Available online 17 April 2004 Abstract Severe hemorrhage is the more frequent complication of thrombolysis, with intracranial bleeding the most critical one. We report a 73- year-old woman with major pulmonary embolism (PE), yet haemodynamically stable, in whom thrombolysis resulted in severe complications with acute renal failure (ARF) due to bilateral renal vein occlusion, quite unexpected; this complication has never been reported, as yet. We believe that disrupture of peripheral vein clots by thrombolysis led to migration of thrombi particles upwards to the inferior vena cava (IVC) and bilateral renal vein occlusion. However, the large thrombus straddled to the bifurcation of the main pulmonary trunk and extending to the right pulmonary artery, as visualized by transthoracic (TTE) and transesophageal echocardiogram (TEE), was not affected by thrombolysis. Finally, endogenous fibrinolytic activity, under low molecular weight heparin, resulted in a slow dissolution of the pulmonary thrombus and restoration of kidney function. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Pulmonary embolism; Thrombolysis; Complications; Renal vein occlusion; Acute renal failure; Echocardiography 1. Introduction The diagnosis of pulmonary embolism (PE) using transthoracic (TTE) or transesophageal echocardiogram (TEE) is based on the identification of right ventricle (RV) overload and/or the direct visualization of thrombi in the right heart or pulmonary arteries [1,2]. The frequen- cy of identifying a thrombus with the use of TTE in patients with massive PE is very low, even if located into the central vasculature as usually happens [1]. In contrast, TEE may detect thrombus in pulmonary arteries in up to 80% in the presence of massive PE [3], with specificity reaching up to 100% [3]. Although, TEE has inherited limitations of visualizing the left pulmonary artery because of the interposition of the left bronchus to the ultrasound beam [1], this is not a major problem when managing patients with significant PE because of the high prevalence of bilateral central pulmonary arterial thrombi in this population [3]. However, the strength of TTE and TEE is that it is a quick bedside diagnostic test, settling echocardiography invaluable in many patients with sus- pected PE who are too ill for transportation out of the intensive care unit (ICU) for further diagnostic procedures [1,4]. Bleeding is the more frequent complication of throm- bolysis. Most bleedings are relatively minor with 70% of episodes occurring at the site of vascular punctures [5]. Intracranial hemorrhage is the most critical complication [5,6]. Allergic reactions may also occur, although rarely especially when recombinant tissue plasminogen activator (rt-PA) is used as thrombolytic agent [5]. To our knowledge, acute renal failure (ARF) due to renal vein occlusion after thrombolysis has not been reported, as yet. We describe a haemodynamically stable patient who admitted in ICU because of major pulmonary embolism. Direct visualization of a large thrombus located at the bifurcation of the main pulmonary trunk and the right artery was performed by TTE and TEE. Thrombolysis resulted in 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.01.035 * Corresponding author. Tel.: +30-3210-7243320; fax: +30-3210- 7216503. E-mail address: ezakynth@yahoo.com (E. Zakynthinos). www.elsevier.com/locate/ijcard International Journal of Cardiology 101 (2005) 163 – 166