A Case of Renal Contusion with Acute Pulmonary Embolism: Treatment Experience and Literature Review_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

HUANG Jifeng , WANG Yubin , TAO Yuhan , ZHANG Yuling , ZHOU Xiaojie ,  MAO Hui

Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R.China;

Corresponding author：

MAO Hui, Email: merrymh@126.com

Keywords：

Pulmonary embolism; Renal contusion; Hemorrhage; Treatment

DOI：

10.7507/1671-6205.202409032

Video：

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Objective To investigate the anticoagulant drug treatment decision for patients with renal contusion and acute pulmonary embolism, and to enhance the level of treatment for this disease. Methods A retrospective analysis of the clinical data of a patient with renal contusion and acute pulmonary embolism treated at the West China Hospital of Sichuan University, along with a relevant literature review. Databases including PubMed, Ovid Medline, Embase, VIP, Wanfang and Chinese National Knowledge infrastructure were searched using the keywords as “Pulmonary embolism” AND “Hemorrhage”from January 1983 to December 2023. Result The patient was a 21-year-old male who presented with right kidney contusion for 5 days and dyspnea for 1 day. The abdominal CT scan revealed a ruptured right kidney accompanied by hemorrhage and hematoma in the surrounding tissue. Abdomen ultrasound: a low echogenic area measuring approximately 10.6 cm×2.8 cm is noted around the right kidney. The CT pulmonary angiography (CTPA) demonstrated filling defects at the bifurcation of the pulmonary trunk, as well as within the upper and lower lobes of both lungs and their respective branches. The blood gas analysis of patient indicated (face mask oxygen therapy at 10 L/min, oxygenation index of 120): pH 7.456, PCO₂ 24.9 mm Hg, PO₂ 73.2 mm Hg. His myocardial markers were Myoglobin: 79.21 ng/ml, Troponin T: 58.7 ng/L, BNP: 2062 ng/L. The patient was diagnosed with renal contusion and pulmonary embolism, and was treated with subcutaneous heparin（initial dose is given as an 80 IU/kg intravenous bolus, followed by a continuous infusion of 12-18 IU/kg/h） and low-molecular-weight heparin at a dose of 0.8 ml every 12 hours one after another for anticoagulation, along with symptomatic treatment. Following the intervention, the patient's respiratory distress showed significant improvement, and subsequent arterial blood gas analysis indicated enhanced oxygenation. Then, the anticoagulant medication was adjusted to oral rivaroxaban anticoagulation for 6 months, follow-up CTPA scan revealed complete resolution of the pulmonary embolism and the abdominal CT scan indicated a reduction in the extent of patchy low-density shadows surrounding the right kidney, leading to the discontinuation of anticoagulation therapy. After searching the above-mentioned databases, total of 26 articles were identified that reported on 30 patients diagnosed with high-risk bleeding and acute pulmonary embolism; among these, 3 patients succumbed while 27 exhibited clinical improvement. Conclusions Patients with renal contusion and acute pulmonary embolism can be safely and effectively treated with low-dose heparin anticoagulation under close monitoring. High-risk bleeding patients with acute pulmonary embolism present a significant challenge in clinical practice. After weighing the risks of bleeding disorders and the adverse outcomes of pulmonary embolism, it is necessary to find the optimal balance between anticoagulation and bleeding. Consequently, the formulation of personalized treatment strategies in accordance with established guidelines can enhance patient outcomes.

Citation： HUANG Jifeng, WANG Yubin, TAO Yuhan, ZHANG Yuling, ZHOU Xiaojie, MAO Hui. A Case of Renal Contusion with Acute Pulmonary Embolism: Treatment Experience and Literature Review. Chinese Journal of Respiratory and Critical Care Medicine, 2024, 23(10): 696-702. doi: 10.7507/1671-6205.202409032 Copy

1.	Endo H, Kubota H, Sato M, et al. Surgical treatment of pulmonary embolism with recent intracranial hemorrhage. Ann Thorac Cardiovasc Surg, 2005, 11(4): 256-259.
2.	Fukuda I, Fukui K, Minakawa M, et al. Rescue surgical embolectomy for fatal pulmonary embolism in patient with intracranial hemorrhage. Ann Thorac Surg, 2006, 81(2): 735-737.
3.	Oneglia C, Gualeni A. Pulmonary embolism after brain hemorrhage in a hypertensive patient: the therapeutic dilemma. J Thromb Thrombolysis, 2007, 25(2): 231-234.
4.	Bulpa P, Carbutti G, Osselaer JC, et al. Low-dose urokinase in massive pulmonary embolism when standard thrombolysis is contraindicated. Chest, 2009, 136(4): 1141-1143.
5.	Mercer RM, Bowen JS, Armstrong RJ. All contraindications to thrombolysis for life-threatening pulmonary embolus should be considered relative. BMJ Case Rep, 2013, 2013: bcr2013009724.
6.	A Bilger, J Pottecher, M Greget et al. Extensive pulmonary embolism after severe postpartum hemorrhage: management with an inferior vena cava filter. Int J Obstet Anesth, 2014, 23: 390-393.
7.	Bottinor W, Turlington J, Raza S, et al. Life-saving systemic thrombolysis in a patient with massive pulmonary embolism and a recent hemorrhagic cerebrovascular accident. Tex Heart Inst J, 2014, 41(2): 174-176.
8.	Middleton R, Neumann J, Ward SM, et al. Successful use of Alteplase during cardiopulmonary resuscitation following massive PE in a patient presenting with ischemic stroke and hemorrhagic transformation. BMJ Case Rep, 2014, 2014,2014: bcr2013200480.
9.	Zuin M, Rigatelli G, Ferrarese S, et al. Acute pulmonary embolism after post-traumatic spinal epidural hematoma: Use of catheter-direct treatment. Cardiovasc Revasc Med, 2017, 18(4): 274-275.
10.	Baumann S, Becher T, Jabbour C et al. Acute pulmonary embolism and contraindication of anticoagulation: Bedside implantation of a new temporary vena cava inferior filter]. Med Klin Intensivmed Notfmed, 2017, 112(3): 246-251.
11.	Wang W. Rivaroxaban plus Percutaneous catheter-directed treatment for a patient with massive pulmonary embolism and colporrhagia. Am J Emerg Med, 2018, 36(8): 1522. e5-1522. e7.
12.	Lee WC, Fang HY. Management of pulmonary embolism after recent intracranial hemorrhage: A case report. Medicine, 2018, 97(15): e0479.
13.	Aiping Y, Shuangyin Z, Yanhong X, et al. Management of intraoperative acute pulmonary embolism in a patient with subarachnoid hemorrhage undergoing femoral fracture repair. J Int Med Res, 2019, 47(10): 5307-5311.
14.	Porche K, Robinson C, Polifka A. Successful Use of Tissue Plasminogen Activator for Saddle Pulmonary Embolism in Peri mesencephalic No aneurysmal Subarachnoid Hemorrhage. World Neurosurg, 2020, 144: 209-212.
15.	Ayers B, Wood K, Cameron S, et al. Surgical Pulmonary Embolectomy with No Systemic Anticoagulation for Patient with Recent Stroke. Ann Thorac Surg, 2020, 110(6): e493-e495.
16.	Kong CY, Fu J, Li N, et al. Management of co-occurring intracranial hemorrhage and fatal pulmonary embolism: a case report. Chin Med J (Engl), 2021, 134(10): 1257-1258.
17.	Rabai F, LaGrew JE, Lazarowicz M, et al. High-Risk Pulmonary Embolism After Hemorrhagic Stroke: Management Considerations During Catheter-Directed Interventional Therapy. J Cardiothorac Vasc Anesth, 2022, 36(9): 3645-3654.
18.	沈建忠. 高血压脑出血并急性肺栓塞1例报告. 井冈山学院学报(自然科学版), 2006, 27(3): 134.
19.	周珊, 张卓然. 3例上消化道出血合并肺栓塞患者临床和相关因素分析. 中国医学工程, 2011, 19(4): 152.
20.	范应磊, 魏林节, 王飞, 等. 高原地区高血压脑出血术后并发肺栓塞1例. 中国社区医师, 2016, 32(3): 172, 174.
21.	童秀萍. 1例急性上消化道出血并发急性肺栓塞患者的护理. 实用临床护理学电子杂志, 2016, 1(10): 28-29.
22.	王东, 潘广新, 马宇洁, 等. 蛛网膜下腔出血并发肺栓塞1例报告. 临床肺科杂志, 2016, 21(5): 961-963.
23.	黄支隆, 胡琼, 姚红梅, 等. 消化道出血合并静脉血栓栓塞症1例报道并文献复习. 贵州医药, 2017, 41(6): 596-597.
24.	吴蓉蓉. 肝癌破裂出血行肝动脉栓塞术术后并发肺栓塞的临床诊断治疗与护理. 世界最新医学信息文摘, 2018, 18(63): 259-260.
25.	郭荣, 刘珍珍. 免疫性血小板减少性紫癜合并肺栓塞及脑出血1例并文献复习. 河南医学研究, 2020, 29(5): 957-959.
26.	马继韬, 唐明星, 蒙旭, 等. 产后大出血早期并发肺栓塞一例. 中华重症医学电子杂志, 2021, 7(4): 372-375.
27.	中华医学会呼吸病学分会肺栓塞与肺血管病学组, 中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会, 全国肺栓塞与肺血管病防治协作组. 肺血栓栓塞症诊治与预防指南. 中华医学杂志, 2018, 98(14): 1060-1087.
28.	28陈小权, 美朗曲措. 不同剂量低分子肝素钠抗凝治疗脑出血合并肺栓塞患者的有效性及安全性比较. 临床合理用药, 2024, 17(4): 70-73.
29.	Schulman S, Anegres U, Bergqvist D, et al. Response to rebuttal, definition of major bleeding in surgery: an anesthesiologist’s point of view. J Thromb Haemost, 2010, 8(6): 1443-1444.
30.	Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J, 2014, 35(43): 3033-3069.
31.	Lisa, Duffett, Lana A, et al. Pulmonary embolism: update on management and controversies. BMJ, 2020, 370: m2177.
32.	Jimenez D, Martin-Saborido C, Muriel A, et al. Efficacy and safety outcomes of recanalisation procedures in patients with acute symptomatic pulmonary embolism: systematic review and network meta-analysis. Thorax, 73(5): 464-471.
33.	John J, Harvey, Shiwei, et al. Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submissive) acute pulmonary embolism Cochrane Database Syst Rev, 2022, 8: CD013083.
34.	Konstantinides S V, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) , Eur Heart J, 2020, 41(4): 543-603.
35.	Jolly M, Phillips J. Embolism: Current Role of Catheter Treatment Options and Operative Thrombectomy. Surg Clin North Am, 2018, 98(2): 279-292.
36.	Carlos R, Martinez Licha, Chelsea M, et al. Current Management of Acute Pulmonary Embolism. Ann Thorac Cardiovasc Surg, 2019, 26: 65-71.
37.	Weinberg A, Tapson VF, Ramzy D. Massive Pulmonary Embolism: Extracorporeal Membrane Oxygenation and Surgical Pulmonary Embolectomy. Semin Respir Crit Care Med, 2017, 38(1): 66-72.
38.	Duffett L, Carrier M. Inferior vena cava filters. Thromb Haemost 2017;15: 3-12.
39.	Mismetti P, Laporte S, Pellerin O, et al. Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism: A Randomized Clinical Trial. JAMA. 2015;313(16): 1627–1635.

1. Endo H, Kubota H, Sato M, et al. Surgical treatment of pulmonary embolism with recent intracranial hemorrhage. Ann Thorac Cardiovasc Surg, 2005, 11(4): 256-259.
2. Fukuda I, Fukui K, Minakawa M, et al. Rescue surgical embolectomy for fatal pulmonary embolism in patient with intracranial hemorrhage. Ann Thorac Surg, 2006, 81(2): 735-737.
3. Oneglia C, Gualeni A. Pulmonary embolism after brain hemorrhage in a hypertensive patient: the therapeutic dilemma. J Thromb Thrombolysis, 2007, 25(2): 231-234.
4. Bulpa P, Carbutti G, Osselaer JC, et al. Low-dose urokinase in massive pulmonary embolism when standard thrombolysis is contraindicated. Chest, 2009, 136(4): 1141-1143.
5. Mercer RM, Bowen JS, Armstrong RJ. All contraindications to thrombolysis for life-threatening pulmonary embolus should be considered relative. BMJ Case Rep, 2013, 2013: bcr2013009724.
6. A Bilger, J Pottecher, M Greget et al. Extensive pulmonary embolism after severe postpartum hemorrhage: management with an inferior vena cava filter. Int J Obstet Anesth, 2014, 23: 390-393.
7. Bottinor W, Turlington J, Raza S, et al. Life-saving systemic thrombolysis in a patient with massive pulmonary embolism and a recent hemorrhagic cerebrovascular accident. Tex Heart Inst J, 2014, 41(2): 174-176.
8. Middleton R, Neumann J, Ward SM, et al. Successful use of Alteplase during cardiopulmonary resuscitation following massive PE in a patient presenting with ischemic stroke and hemorrhagic transformation. BMJ Case Rep, 2014, 2014,2014: bcr2013200480.
9. Zuin M, Rigatelli G, Ferrarese S, et al. Acute pulmonary embolism after post-traumatic spinal epidural hematoma: Use of catheter-direct treatment. Cardiovasc Revasc Med, 2017, 18(4): 274-275.
10. Baumann S, Becher T, Jabbour C et al. Acute pulmonary embolism and contraindication of anticoagulation: Bedside implantation of a new temporary vena cava inferior filter]. Med Klin Intensivmed Notfmed, 2017, 112(3): 246-251.
11. Wang W. Rivaroxaban plus Percutaneous catheter-directed treatment for a patient with massive pulmonary embolism and colporrhagia. Am J Emerg Med, 2018, 36(8): 1522. e5-1522. e7.
12. Lee WC, Fang HY. Management of pulmonary embolism after recent intracranial hemorrhage: A case report. Medicine, 2018, 97(15): e0479.
13. Aiping Y, Shuangyin Z, Yanhong X, et al. Management of intraoperative acute pulmonary embolism in a patient with subarachnoid hemorrhage undergoing femoral fracture repair. J Int Med Res, 2019, 47(10): 5307-5311.
14. Porche K, Robinson C, Polifka A. Successful Use of Tissue Plasminogen Activator for Saddle Pulmonary Embolism in Peri mesencephalic No aneurysmal Subarachnoid Hemorrhage. World Neurosurg, 2020, 144: 209-212.
15. Ayers B, Wood K, Cameron S, et al. Surgical Pulmonary Embolectomy with No Systemic Anticoagulation for Patient with Recent Stroke. Ann Thorac Surg, 2020, 110(6): e493-e495.
16. Kong CY, Fu J, Li N, et al. Management of co-occurring intracranial hemorrhage and fatal pulmonary embolism: a case report. Chin Med J (Engl), 2021, 134(10): 1257-1258.
17. Rabai F, LaGrew JE, Lazarowicz M, et al. High-Risk Pulmonary Embolism After Hemorrhagic Stroke: Management Considerations During Catheter-Directed Interventional Therapy. J Cardiothorac Vasc Anesth, 2022, 36(9): 3645-3654.
18. 沈建忠. 高血压脑出血并急性肺栓塞1例报告. 井冈山学院学报(自然科学版), 2006, 27(3): 134.
19. 周珊, 张卓然. 3例上消化道出血合并肺栓塞患者临床和相关因素分析. 中国医学工程, 2011, 19(4): 152.
20. 范应磊, 魏林节, 王飞, 等. 高原地区高血压脑出血术后并发肺栓塞1例. 中国社区医师, 2016, 32(3): 172, 174.
21. 童秀萍. 1例急性上消化道出血并发急性肺栓塞患者的护理. 实用临床护理学电子杂志, 2016, 1(10): 28-29.
22. 王东, 潘广新, 马宇洁, 等. 蛛网膜下腔出血并发肺栓塞1例报告. 临床肺科杂志, 2016, 21(5): 961-963.
23. 黄支隆, 胡琼, 姚红梅, 等. 消化道出血合并静脉血栓栓塞症1例报道并文献复习. 贵州医药, 2017, 41(6): 596-597.
24. 吴蓉蓉. 肝癌破裂出血行肝动脉栓塞术术后并发肺栓塞的临床诊断治疗与护理. 世界最新医学信息文摘, 2018, 18(63): 259-260.
25. 郭荣, 刘珍珍. 免疫性血小板减少性紫癜合并肺栓塞及脑出血1例并文献复习. 河南医学研究, 2020, 29(5): 957-959.
26. 马继韬, 唐明星, 蒙旭, 等. 产后大出血早期并发肺栓塞一例. 中华重症医学电子杂志, 2021, 7(4): 372-375.
27. 中华医学会呼吸病学分会肺栓塞与肺血管病学组, 中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会, 全国肺栓塞与肺血管病防治协作组. 肺血栓栓塞症诊治与预防指南. 中华医学杂志, 2018, 98(14): 1060-1087.
28. 28陈小权, 美朗曲措. 不同剂量低分子肝素钠抗凝治疗脑出血合并肺栓塞患者的有效性及安全性比较. 临床合理用药, 2024, 17(4): 70-73.
29. Schulman S, Anegres U, Bergqvist D, et al. Response to rebuttal, definition of major bleeding in surgery: an anesthesiologist’s point of view. J Thromb Haemost, 2010, 8(6): 1443-1444.
30. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J, 2014, 35(43): 3033-3069.
31. Lisa, Duffett, Lana A, et al. Pulmonary embolism: update on management and controversies. BMJ, 2020, 370: m2177.
32. Jimenez D, Martin-Saborido C, Muriel A, et al. Efficacy and safety outcomes of recanalisation procedures in patients with acute symptomatic pulmonary embolism: systematic review and network meta-analysis. Thorax, 73(5): 464-471.
33. John J, Harvey, Shiwei, et al. Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submissive) acute pulmonary embolism Cochrane Database Syst Rev, 2022, 8: CD013083.
34. Konstantinides S V, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) , Eur Heart J, 2020, 41(4): 543-603.
35. Jolly M, Phillips J. Embolism: Current Role of Catheter Treatment Options and Operative Thrombectomy. Surg Clin North Am, 2018, 98(2): 279-292.
36. Carlos R, Martinez Licha, Chelsea M, et al. Current Management of Acute Pulmonary Embolism. Ann Thorac Cardiovasc Surg, 2019, 26: 65-71.
37. Weinberg A, Tapson VF, Ramzy D. Massive Pulmonary Embolism: Extracorporeal Membrane Oxygenation and Surgical Pulmonary Embolectomy. Semin Respir Crit Care Med, 2017, 38(1): 66-72.
38. Duffett L, Carrier M. Inferior vena cava filters. Thromb Haemost 2017;15: 3-12.
39. Mismetti P, Laporte S, Pellerin O, et al. Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism: A Randomized Clinical Trial. JAMA. 2015;313(16): 1627–1635.

Chinese Journal of Respiratory and Critical Care Medicine

A Case of Renal Contusion with Acute Pulmonary Embolism: Treatment Experience and Literature Review

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