Revista Agrária Acadêmica
doi: 10.32406/v6n6/2023/59-67/agrariacad
Acute paralysis due to aortic thromboembolism in a cat – case report. Paralisia aguda devido a tromboembolismo aórtico em um gato – relato de caso.
Omar Gutierrez Velasquez
1*, Joanna Bandero Escobar1,2, Angélica La Roque Machado1,2, Maicon Pinheiro1, Igor Dumaszak1, Eduardo Everling1, Leonardo Schneider1, Isadora Colpo1, Marina Grün Bohn1, Moises Gorgônio1, Raissa Gomes1, Luciana Dutra1, Renata Rossato Milanesi1,3
1- Hospital Veterinário Ninho (HVN), Santa Maria, Rio Grande de Sul, Brasil.
2- Curso de Medicina Veterinária, Universidade Regional Integrada do Alto Uruguai e das Missões (URI), Santiago – Rio Grande de Sul, Brasil.
3- Curso de Medicina Veterinária, Universidade Federal de Santa Maria (UFSM), Santa Maria, Rio Grande de Sul, Brasil.
* Autor correspondente: Av. João Luiz Pozzobon, 1625, Km-3, CEP 97095-465, Santa Maria, Rio Grande de Sul. Phone: (55) 9 9914-7889. E-mail: otaly12345@gmail.com
Abstract
Feline aortic thromboembolism is a cardiovascular disease that affects the feline species, with acute paralysis being one of the forms of clinical presentation. The objective of this clinical case is to describe the clinical and therapeutic management of a cat with acute paralysis due to aortic thromboembolism. A general physical examination and complementary tests were performed to diagnose aortic thromboembolism and subsequent pharmacological treatment associated with the surgical intervention. It is concluded that it is possible to reverse acute paralysis due to thromboembolism through definitive diagnosis and initiation of thrombolytic treatment associated with the surgical procedure.
Keywords: Diagnosis. Feline. Embolism. Surgery. Paralysis.
Resumo
O tromboembolismo aórtico felino é uma doença cardiovascular que acomete a espécie felina, sendo a paralisia aguda uma das formas de apresentação clínica. O objetivo deste caso clínico é descrever o manejo clínico e terapêutico de um gato com paralisia aguda por tromboembolismo aórtico. Um gato foi tratado por paralisia aguda dos membros pélvicos. Foram realizados exame físico geral e exames complementares para diagnóstico de tromboembolismo aórtico e posterior tratamento farmacológico associado à intervenção cirúrgica. Conclui-se que é possível reverter a paralisia aguda por tromboembolismo através do diagnóstico e início do tratamento trombolítico associado ao procedimento cirúrgico.
Palavras-chave: Diagnóstico. Felino. Embolia. Cirurgia. Paralisia.
Introduction
Feline aortic thromboembolism is a cardiovascular disease that mainly affects the feline species, being a painful episode characterized by acute ischemic necrosis of one or both pelvic limbs, which can cause the patient’s death (GIL-ORTUÑO et al., 2020). Among the most common causes that generate this type of episode are cardiomyopathies (PETRUSHKO; GRUSHANSKA, 2023), hyperthyroidism (SUTTON; LONG MAYS; MCLAUGHLIN, 2022), nephropathy (GARDINER, 2020) and neoplasms (GUARINO et al., 2021).
The process of aortic thromboembolization normally begins with the release of thrombotic material originating in the left atrium due to changes in the heart muscle that ends up lodging in the bifurcation regions of the aorta artery (GUILLAUMIN et al., 2019). The development of a thrombotic process requires some characteristics such as aortic vascular endothelial alteration, blood stasis, altered coagulation factors, hypercoagulability, among others (CHO; KIM, 2020).
Symptoms have an acute onset, patients arrive at the clinic with pain, vocalization, hypoglycemia in the affected limb compared to systemic glycemia, lack of arterial pulse, rhabdomyolysis and paralysis in the pelvic limbs (BURKE; REINEKE, 2022).
The prognosis is poor, most affected cats are euthanized at the time of clinical examination, patients who receive pharmacological and/or surgical treatment are at risk of death from systemic hemodynamic reperfusion due to oxidative stress (SURACHETPONG et al., 2020).
The diagnosis is usually made through clinical examination and can be confirmed with the help of complementary tests such as infrared thermography (POUZOT-NEVORET et al., 2018), vascular ultrasound (MAYS; PHILLIPS, 2021), tomography and magnetic resonance angiography (LEE et al., 2015).
Treatment can be pharmacological (MITROPOULOU et al., 2022), consisting of the dissolution of the thrombus and vascular surgery (VEZZOSI et al., 2020).
The objective of this clinical case is to describe the clinical and therapeutic management of a cat with acute paralysis due to aortic thromboembolism.
Case report
A 4-year-old castrated cat, undefined breed, weighing 4 kg, was treated at the veterinary hospital Ninho, located in the city of Santa Maria, Rio Grande do Sul, Brazil, due to acute paralysis of the pelvic limbs and episodes of vocalization due to pain during handling. The additional medical history reported by the owner was that the patient began to stop moving his pelvic limbs at home two hours before arriving at the hospital, with no other history of illness and with up-to-date vaccinations, the veterinarian suspected thromboembolism.
Upon admission for physical examination, the patient presented tachycardia (191 beats per minute), tachypnea (55 breaths per minute), absence of bilateral femoral pulse, pale to cyanotic foot pads, temperature 37.5°C, and pulmonary and cardiac auscultation without changes. Given the presence of discomfort and pain in the patient, he was medicated with methadone 0.3 mg/kg and dipyrone 12.5 mg/kg, both medications administered subcutaneously with the aim of better management and performance of diagnostic procedures for the patient.
With the idea of diagnosing aortic thromboembolism through physical examination, we proceeded to search for pulsatile flow of the femoral artery in the pelvic limbs using vascular Doppler, where an absence of femoral flow was found. In the absence of blood flow and with the idea of understanding cellular metabolism, the glycemia of the pelvic limbs was measured in the region of the plantar pads to compare it with the systemic glycemia at the tip of the ear, the results were 50 mg/dl for the leg left, 35 mg/dl for the right leg and 258 mg/dl for systemic glycemia. Once changes in femoral blood flow and blood glucose values are observed, the patient is referred to the ultrasound service to try to find a definitive diagnosis.
Ultrasound assessment was performed in the patient’s supine position. The aorta artery was visualized in the sagittal and transverse planes using a linear transducer. The thrombotic structure was found in the region of the bifurcation of the iliac arteries and was described as a heterogeneous hyperechoic image that occupied 90% of the diameter of the aorta artery and occluded the passage of blood flow to the iliac arteries evaluated by Doppler (Figure 1). Na presença dos sintomas do paciente e de evidências ultrassonográficas, o tromboembolismo aórtico foi considerado diagnóstico definitivo e o animal foi encaminhado para avaliação cardiológica antes de ser submetido ao procedimento cirúrgico para retirada do trombo. Na avaliação cardiológica o animal apresenta alterações no exame ecocardiográfico onde se observa aumento de espessamento no músculo cardíaco, imagens compatíveis com cardiomiopatia hipertrófica.
Figure 1 – Ultrasonography of the abdominal aorta artery. The yellow arrow shows the thrombus that is blocking the passage of blood flow.
Once the definitive diagnosis was found, blood tests were performed (hemogram and biochemistry) where there were no changes in the results and the animal was prepared for the surgical procedure. Venous access was placed in the left cephalic vein with a number 24.0 catheter to perform the anesthetic procedure. The patient was anesthetized with 5.0 mcg/kg of fentanyl and 4.0 mg/kg of propofol, both medications administered intravenously. Once the animal lost swallowing and eyelid reflexes, it was intubated with a 3.5 mm diameter endotracheal tube and coupled to an isoflurane inhalation anesthetic system with an oxygen flow of 100.0 ml/kg/minute. As an analgesic protocol for surgery, ultrasound-guided transversus abdominis plane anesthetic block (TAP-BLOCK) (Figure 2) and continuous infusion of ketamine and fentanyl were performed at a rate of 0.6 mg/kg/hour and 5.0 mcg/kg/hour, respectively.
Figure 2 – Ultrasound of anesthetic block in the transverse abdominal plane (TAP-BLOCK). The yellow arrow shows the deposition of local anesthetic in the muscles of the abdominal wall.
After carrying out the anesthetic procedure, the animal was placed in the supine position and the abdominal region was prepared antiseptically with chlorhexidine for the surgical procedure. A celiotomy was performed to identify the thrombotic structure in the region of the abdominal aorta and the bifurcation of the iliac arteries. After localizing the thromboembolism, vascular slings were used for atraumatic clamping of the abdominal aorta immediately proximal to the thrombus at the level of the caudal region of the renal arteries to prevent renal failure and in the region of the iliac arteries at the level distal to the thrombus. An approximately 50 mm incision was made on the ventral surface of the aorta and the thrombotic material was subsequently removed. The aorta was sutured with 6-0 absorbable polydioxanone thread in a simple interrupted pattern (Figure 3). In the absence of bleeding complications, the abdominal wall muscles and skin were sutured with polydioxanone and nylon, respectively.
The patient recovered well from anesthesia and was transferred to the intensive care unit for better care and monitoring of vital signs. The cat was admitted receiving medication of methadone 0.3 mg/kg, dipyrone 12.5 mg/kg and heparin 100.0 IU/kg subcutaneously three times a day, meloxicam 0.1 mg/kg subcutaneously once a day , clopidogrel 18.75 mg/cat orally every 24 hours and ceftriaxone 30.0 mg/kg intravenously twice a day. 24 hours after surgery, the cat had a palpable femoral pulse, femoral artery flow was found on vascular Doppler, the color of the paw pads was normal, and blood glucose values in the pelvic extremities were similar to systemic blood glucose values. The acute paralysis was no longer present and the animal had resumed normal locomotion.
During the entire hospitalization, the patient had continuous monitoring of his physiological parameters and control of blood count, renal function, liver function and coagulation tests. 48 hours after surgery, abdominal ultrasound was repeated to assess blood flow in the aorta and iliac arteries. As no changes in blood flow were observed on ultrasound, the patient was discharged from the hospital. The patient was discharged receiving medication of clopidogrel 18.75 mg/cat, amoxicillin 10 mg/kg, tramadol 2.0 mg/kg, dipyrone 12.5 mg/kg and pimobendan 0.3 mg/kg, all orally.
Ten days after hospital discharge, the cat returned to the hospital to have the stitches removed from the skin and the owner reported that the patient was stable and had no other changes in health status.
Figure 3 – Surgical procedure to remove thrombotic material. The yellow arrow shows the suturing of the aorta artery after thrombus removal.
Discussion
This case report describes the presentation of a cat with aortic thromboembolism, which was successful in both diagnosis and treatment, since this type of pathological change mainly affects the cardiovascular system due to the formation of thrombotic material that leads to obstruction of blood flow (ROSSI et al., 2020). For this reason, the time factor is considered important in this type of changes, since the first six hours after obstruction of blood flow in a hypoperfused region are considered very critical and interfere with the animal’s survival (HASSAN et al., 2020).
The patient in this case arrived at the hospital with signs of pain, paralysis and lack of pulse in the pelvic limbs with possible rhabdomyolysis. Normally this type of presentation has a lot to do with the embolization of the thrombus resulting in ischemia in the region where the thrombotic material obstructs the blood flow, causing the animal to have a sudden onset of pain, anguish and vocalization (LI et al., 2022). Clinical signs depend mainly on the location of the thrombus, with paralysis of the pelvic limbs being one of the most common in this type of pathological changes (TOSUWAN; HUNPRASIT; SURACHETPONG, 2021).
The way aortic thromboembolism is diagnosed in relation to other diseases that cause acute paralysis is based on clinical history, physical assessment, and presentation of clinical signs. In our case, given the clinical history presented by the owner, our suspicion was directed towards the diagnosis of aortic thromboembolism, so one way to assess the absence of blood flow at the distal level of the thrombus in the pelvic limbs is through the use of a Doppler vascular, where unfortunately no blood flow was found, so we opted for another form of assessment, which is measuring blood glucose in the distal region of the thrombus, where values are low in relation to systemic blood glucose due to hypoperfusion caused by thrombosis (KLAINBART et al., 2014). Dada a história clínica, sinais clínicos e procedimentos realizados visando o tromboembolismo, obtivemos um diagnóstico definitivo através do uso da ultrassonografia (EBERLÉ et al., 2022), mas outros tipos de procedimentos tecnológicos também podem ser utilizados para obter um diagnóstico preciso e definitivo que pode ser feito através do uso da tomografia (LEE et al., 2023).
Once the definitive diagnosis was made in our case and before the surgical procedure was performed, the patient was referred to the cardiology service for complete evaluation, where the echocardiogram results were suggestive of hypertrophic cardiomyopathy of the left ventricle, this type of cardiac alteration is the cause of origin of the clot in the left atrium which subsequently goes to the blood vessels where it ends up obstructing blood flow (CHETBOUL et al., 2019). There are also other pathological changes that can lead to thrombus formation, such as hyperthyroidism, hypertension, neoplasms, among others (AHN et al., 2019).
Once heart failure was ruled out in the cardiological evaluation, the patient was prepared for the anesthetic and surgical procedure. The anesthetic protocol in this case was consistent with hypnosis, muscle relaxation, monitoring of the autonomic system and adequate analgesia, therefore balanced anesthesia and multimodal analgesia techniques were used for better hemodynamic control during the surgical procedure (IMANI RASTABI et al., 2019). Typically, cats with thromboembolism undergoing a surgical procedure present many hemodynamic changes due to obstruction of blood flow caused by thrombosis, and these changes are a negative factor at the time of the anesthetic procedure (YILDIRIM; ALBAYRAK, 2023).
One of the ways to dilute the obstructive clot is through thromboembolic therapy, but the results are mostly unsatisfactory (GUILLAUMIN et al., 2022). For this reason, our surgical treatment was our first option in addition to the use of thromboembolic medication postoperatively (RUEHL et al., 2020). Some studies also suggest that clot removal can be achieved through a minimally invasive approach considered an interventional strategy (GAVIN; WEISSE; BERENT, 2022).
One of the changes that normally occurs after thrombus removal is reperfusion syndrome, considered a potential and fatal risk for the patient (SHAVERDIAN; LI, 2023). Reperfusion syndrome injury typically induces a systemic inflammatory response that leads to the failure of different systems in the animal’s body (WANG et al., 2019). To evaluate these changes produced by reperfusion syndrome, in our case the blood count, renal profile, liver profile and electrolytes were monitored after the surgical procedure as a way of evaluating the systemic inflammatory response.
Conclusion
In conclusion, this case report suggests that it is possible to reverse acute paralysis caused by aortic thromboembolism as long as it is possible to make a definitive diagnosis and initiate thrombolytic medical treatment associated with a surgical procedure.
Conflict of interests
All authors declare that there is no conflict of interest for the publication of this work.
Authors’ contributions
Omar Gutierrez Velasquez, reading and interpretation of works and writing. Other components helped with corrections and review of the work.
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Recebido em 18 de setembro de 2023
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Recebido com ajustes em 23 de janeiro de 2024
Aceito em 25 de janeiro de 2024