cat with saddle thrombus

Re: cat with saddle thrombus

Zoltan dr. Szabo — Mon, 23 Jul 2012 20:02:40 GMT

I had an accident 3 years ago, 2 weeks after I had a thromboembolism in my left lung. It was a horribly painful feeling. When I was taken into the hospital, a cardiologist said to me: Don't worry, the big embolism isn't painful but everybody gets die, and the small embolism is a very-very painful situation but somebody can survive.

So I think if there is big pain, we have to try treating the patient. But our obligation is to reduce the measure of the pain.

Re: cat with saddle thrombus

Lorna McHardy — Mon, 23 Jul 2012 19:01:22 GMT

[quote user="Rajat"]

Try VASG.org - a great resource for veterinary anaesthesia and analgesia.

[/quote]

Thank you; I'll look at that.

[quote user="Rajat"]

Re lidocaine - if you have the IV formulations (sans preservative) you can use it - it is diluted anyways for the CRI. Many texts advocate against lidocaine in cats but it can be used but at much lower doses than dogs- VASG should have more info.

[/quote]

Of course, not in cats... I'd moved to the general again but I did know that :0)

Sod's law... haven't seen a case in ages, and the minute there's a thread about it on here, I get two in one weekend :0(( They were both in screaming agony, and they're both now dead... then there was the ethylene glycol poisoning and the ancient dog off its back legs... can I stop killing things for a while, now, please :0(((

Re: cat with saddle thrombus

Rajat — Mon, 23 Jul 2012 12:18:29 GMT

[quote user="Alexa Bardell"]

Hi all

Having opened a can of worms I now have an update on the original case!

Cat has regained full use of left hind but right hind still has proprioceptive deficits. All foot pads are warm adn since are unpigmented can assess perfusion which looks adequate. Cat is comfortable so has gone home with reg checkups. Owner has got a harness and lead so can take out into garden without risk of running off on 3 legs and getting stuck somewhere. Also plan to add in acupuncture and physio sessions. Have warned may well not regain full use of right hind but as cat seems happy at home am willing to take things as they come.

[/quote]

Fantastic, thanks for the update- and thanks for stimulating discussion too. Its always interesting to see how people treat these cases..

Re: cat with saddle thrombus

Rajat — Mon, 23 Jul 2012 12:17:37 GMT

[quote user="Lorna McHardy"] On a slightly different note, do you think our pets have a sense of a future? [/quote]

Hi Lorna, well to some extent I think they do - as in cats wait for us to come home, anticipate food and company in a manner that suggests they know what the immediate future contains- but I don't think they have cognitive capacities which allow them to have future plans in a similar sense to us (re what we would miss should we die tomorrow). So difficult to know though, isn't it?

[:[quote user="Lorna McHardy"] NSAID +/- buprenorphine definitely not enough.[/quote]^)] - Completely agree

Try VASG.org - a great resource for veterinary anaesthesia and analgesia. Lots of drug info excel sheets protocols and so on.

Best

Raj

Re: cat with saddle thrombus

a.bardell — Sat, 21 Jul 2012 12:51:25 GMT

Hi all

Having opened a can of worms I now have an update on the original case!

Re: cat with saddle thrombus

Lorna McHardy — Sat, 21 Jul 2012 00:20:56 GMT

Rajat... I only work in one practice where there's the option of an analgesia CRI (methadone/ketamine). I've tried that and found it insufficient... I'd have to look up my doses; I got them from a RVC CPD. There's no suitable strength lignocaine available, or I'd add that also. NSAID +/- buprenorphine definitely not enough.

I'm getting the impression that everyone's actually pretty much in agreement over this... treat provided the cat's pain can be controlled; which is where the agree to disagree thing comes in. On a slightly different note, do you think our pets have a sense of a future? I ask because I think you'd need that for longevity to be something of importance or euthansia to be a welfare issue for the cat. You and I know what we'd be likely to be missing were we to be run over by a bus tomorrow, but do our pets?

Re: cat with saddle thrombus

Rajat — Fri, 20 Jul 2012 19:34:51 GMT

[quote user="Lorna McHardy"] could be wrong here, but that actually sounds as though you were - intentionally or unintentionally - selecting for owners whose inability to let go of their cat outweighs the cat's suffering. I don't think that's a good thing, and believe that part of what we need to do, is present owners with advice. The bit where I disagree with you (and yes, you're making perfect sense ), is where you reckon the pain of a clot is controllable. [/quote]

I can see why I came across like that (re reading, and yes was typing between consults!) but really, I think this requires a long chat and without meaning to sound wishy washy I will try to see if people are really commited to their cats welfare and care. Those that are emotional wrecks and bawling and saying yes do everything I love fluffy I dont care what it costs or involves are not thinking rationally - I will analgese the cat to the eyeballs but have the same chat again few hours later. The bit I need to know is someone at home most of the day? Can the cat be pilled or is it semi feral? Do they have the money to spend? do they understand all the ins and outs, and yes sometimes it takes a lot of consulting time, telephone time, printouts from fabcats and so on... but overall I dont think I cave in to the 'insured and wealthy emotionally super attached' clients, rather I try to elucidate those who can actually go the whole hog AND understand what they are getting into - those who cannot I will recommend euthanasia to whole heartedly.

[quote user="Lorna McHardy"]In a nutshell: if the pain is controllable, fair enough. If not, not. And it usually isn't, which I discover every damn time I'm persuaded to treat, and end up euthanasing anyway, after the cat's suffered some more.[/quote]

Re pain of clot - well you and I both know pain in cats is difficult to detect in most cases. But the acute pain of a clot is easier to assess vis a vis response to analgesics IMHO - just like an RTA kitty given morphine ket CRI goes from crazy vicious cat to purring softie!

I can't argue the point, we can just agree to disagree, as neither one of us can communicate with cats. But with an interest in pain management, and a total aversion to any pain in any of my patients I can say that with aggressive management of analgesic requirements in these patients, it is possible to control pain in the majority. I have wondered about morphine epidurals but never attempted one in these, this would give total control over pain, and after first 24 h or so when the ischaemic neuropathy wears off these kitties are much more comfy anyways.What protocol have you or would you use for pain management in these cases out of interest?

[quote user="Lorna McHardy"]dubious benefit of keeping them for a year longer if I'm lucky, and the near-certainty they'll suffer the same pain again next time. Euthanasia, after all, is not a welfare issue for the cat; although I accept it might well be for the owner.[/quote]

I don't see the benefit to the owner alone but also to the cat. 6 months is 1/30th of an average feline lifespan. Which is 2 years for us as humans - not exactly short for me! Of course if suffering, put it out of its misery but if meds can keep it 'suffering free' for an additional 6-12 months, in the right case then why not is my approach.

All this said, this is one disease where I am ready to PTS unless ALL my boxes get ticked. I just thought I'd stand up for treatment in the cases where it can be pursued under the right circumstances...

Re: cat with saddle thrombus

Rajat — Fri, 20 Jul 2012 19:09:59 GMT

[quote user="Julian Earl"]f, if, if... so do 50% survive for months or a year? Can we and do we offer extremely good and effective analgesia in these cases. If the answer is no to any of these then I don't care how committed the owners are, the advice should be to euthanase.[/quote]

Can we - Yes IMHE- in addn to proposed protocol prev, I also suggest ketamine CRI +/- lidocaine (very low dose, can be used safely in cats!) + gabapentin for neuropathic pain from ischaemic neuropathy. It is amazing the difference multimodal pain management can make to these kitties!

Do we - Just like any other condition if we cant treat it we should offer alternatives- referral or euthanasia in this situation... if we cannot control this pain. Humbly, I propose, if one of us as veterinary surgeons does not have access to pure opiates 24 hour care, syringe drivers or infusion pumps to titrate powerful analgesics then we should not be treating these cats - and should refer or euthanase if referral to another veterinary practice (note not saying specialist!) is not possible.

In the paper DM mentioned first (Smith et al, JVIM 2003) approx 50% survive to be discharged. Of survivors, those with CHF had shorter median survival times than those without (though they mostly died due to trouble with controlling CHF rather than due to FATE). The survivors without CHF lived on average 7.5 months.

I think this paper is very useful BUT worth remembering the heterogeneity of treatment protocols in this paper, its retrospective nature and the fact it was run over a decade, starting 1992 - there is more info out there now and I think survival would be higher with current protocols and drugs/treatment protocols. I know some specialists feel that too but that is anecdote, just a wee fragrance on the breeze nothing more substnatial

I agree with the bit about if we don't control pain well for whatever reason, PTS is the best option.

Re: cat with saddle thrombus

Lorna McHardy — Fri, 20 Jul 2012 18:37:04 GMT

[quote user="Rajat"]

I am often torn between what to reccommend for these cats so I present all facts to owners, have a heart to heart and try to gauge how they feel and how commited they are...some you know straight away that wont be good candidates (owners..) others commit initially then waver later on.I don't think euthanasia is a bad option, but if 50% of cats ruvive to discharge and live for many months toa year AND if we are able to treat their pain in the acute phase successfully, then it is not unreasonable to offer treatment and is unreasonable to say unconditionally euthanasia is the best option...if that makes any sense..

But I think a year is a long time for a cat to live. I know if it was my own I would pursue treatment. On which note my damn little fat cat has gone and got HCM as well. discovered the murmur on the day of her dental-= great! As if having chronic obesity and IBD wasn't enough. she also suffers from severe chronic non season feline lethargy syndrome...anyone got any suggestions ?

[/quote]

I could be wrong here, but that actually sounds as though you were - intentionally or unintentionally - selecting for owners whose inability to let go of their cat outweighs the cat's suffering. I don't think that's a good thing, and believe that part of what we need to do, is present owners with advice. The bit where I disagree with you (and yes, you're making perfect sense ), is where you reckon the pain of a clot is controllable.

Now obviously, it depends on the clot and maybe I've been unlucky; but my personal experience is that that pain is nearly always poorly controlled... the very occasional apparent exception doesn't change that. That alone is a strong argument for euthanasia, only outweighed, in my opinion, by the likelihood of a cure, or at least a small chance of recurrance... neither of which apply to this disease. In a nutshell: if the pain is controllable, fair enough. If not, not. And it usually isn't, which I discover every damn time I'm persuaded to treat, and end up euthanasing anyway, after the cat's suffered some more.

I wouldn't put my own cats through that kind of pain for the dubious benefit of keeping them for a year longer if I'm lucky, and the near-certainty they'll suffer the same pain again next time. Euthanasia, after all, is not a welfare issue for the cat; although I accept it might well be for the owner.

No suggestions for your cat... I'm pretty sure you know what you're doing l

Re: cat with saddle thrombus

Rajat — Fri, 20 Jul 2012 17:51:56 GMT

[quote user="Mark Holmes"]people often forget when they quote success rates about those that aren't successful.[/quote]

I think most people understand what a 50% success rate means...half will survive to discharge half won't. Yes the cat is in terrible pain, but the pain can be controlled with strong drugs and will dissipate in 24-36 hours.

[quote user="Mark Holmes"]I think there is a level when the likely hood of success is sufficiently small that to proceed is unfair[/quote]

IMHO this is a personal choice to be made by the owner not us - many ppl dont think 50%+ survival to discharge rates are small success rates and for some ppl any condition requiring treatment equates to euthanasia.

Re: cat with saddle thrombus

Julian Earl — Fri, 20 Jul 2012 17:44:34 GMT

[quote user="Rajat"]

[quote user="Julian Earl"] just to save one for months or even a year.[/quote]

[/quote]

If, if, if... so do 50% survive for months or a year? Can we and do we offer extremely good and effective analgesia in these cases. If the answer is no to any of these then I don't care how committed the owners are, the advice should be to euthanase.

Re: cat with saddle thrombus

Rajat — Fri, 20 Jul 2012 17:39:22 GMT

[quote user="Julian Earl"] just to save one for months or even a year.[/quote]

Re: cat with saddle thrombus

Mark Holmes — Fri, 20 Jul 2012 16:50:51 GMT

[quote user="Julian Earl"]I do not believe we can justify attempting treatment on, say ten, just to save one for months or even a year[/quote]

Absolutely - people often forget when they quote success rates about those that aren't successful. Given how stressful many animals find the hospital experience even if in relative comfort. I think there is a level when the likely hood of success is sufficiently small that to proceed is unfair, particularly when it is sometime before you know if you will succeed or fail. If there is a poor prognosis and the result only becomes apparant over a prolonged period you have to consider the experience of the failures as much as the successes.

Re: cat with saddle thrombus

Rajat — Fri, 20 Jul 2012 16:39:21 GMT

Hi Martin

If you published a case series showing your stats and claims, I would humbly accept it. But anecdote means not much at all in the face of published peer reviewed evidence to the contrary. As it stands, ppl attempting and carrying out this surgery in my eyes are not heroes..put yourself in the cats shoes like I said previously and see if you would want to be operated on if it made no difference according to published studies but there was one local surgeon (maybe another in Wales !:) who claimed he had great success rates despite all consultants saying otherwise- would you agree to have your or your child's aorta cut open to have the clot removed despite these stats? Don't mean to be dramatic saying your child, just that ppl often have these weird relationships (parent-child) with their pets, I know I do, my fat cat is my baby!!

Re: cat with saddle thrombus

Richard Fox — Fri, 20 Jul 2012 12:52:14 GMT

[quote user="Rajat"]

Re heparin etc- ppl absolutely right it does not dissolve the clots (TPA/Streptokinase can do this but again are NOT recommended http://www.ncbi.nlm.nih.gov/pubmed/19740689). but using aspirin clopidrogel and heparin together to inhibit various parts of the clotting cascade can prevent the clot getting bigger (in the heart or aorta). there is one study of intra-arterial urokinase resulting in impriovement without adverse effects- I think we need a larger study than n=1!! http://www.ncbi.nlm.nih.gov/pubmed/20379085.

[/quote]

Sound info to me :)

Re: cat with saddle thrombus

Julian Earl — Fri, 20 Jul 2012 12:50:54 GMT

[quote user="Rajat"]

My approach in response to OP if O agrees to all above is :

1.fentanyl CRI ...

[lots of interesting information]

I agree overall euthanasia is the BEST IF the owners are not

a) financially commited to spending +++

b) emotionally commited to the cat

c) willing to come in for regular checks exams and tests

d)aware things can go wrong at any stage and the cat prob wont live longer than a year

I have treated cats successfully with CHf for > 6 mo and withotu CHF > 1 year.

[/quote]

I would humbly suggest a minor modification to the above:

"I agree overall euthanasia is the BEST EVEN IF the owners are

a) financially commited to spending +++

b) emotionally commited to the cat

c) willing to come in for regular checks exams and tests

d)aware things can go wrong at any stage and the cat prob wont live longer than a year"

Simply on the grounds that these cats are in such extreme pain, and the risk of further complications so high, that I do not believe we can justify attempting treatment on, say ten, just to save one for months or even a year. If my inferred stats are wrong, and the pain relief is extremely good, then fair enough, but sometimes enough is enough.

Re: cat with saddle thrombus

Martin Atkinson — Fri, 20 Jul 2012 12:36:20 GMT

[quote user="Rajat"]

Oh and one more thing - specialists in these disciplines are upto date with all the recent ifno literature as well as anecdote (gasp!) from their peers- so if NO specialist is doing something all around the world (eg clot removals from the aorta) the chances are there is a very good reason for this!

[/quote] In the words of Hugh Cornwell (The Stranglers for the uninitiated): 'Whatever happened to the heroes?....no more heroes any more, they wash their own bums'. More seriously I think it is not because it doesn't work, because it does and spectacularly so, but for fear of surgical complications, recurrence and complicating factors due to cardiac disease. I don't promote it as the primary treatment option, but It is an option for carefully selected cases.

Re: cat with saddle thrombus

Rajat — Fri, 20 Jul 2012 11:54:45 GMT

Re: cat with saddle thrombus

Rajat — Fri, 20 Jul 2012 11:52:56 GMT

My approach in response to OP if O agrees to all above is :

1.fentanyl CRI or Morphine-ketamine CRI - these are EXTREMELY painful even if cats dont show signs of pain well, a mu agonist is recommended, preferably by CRI to prevent peaks and troughs in plasma concentrations of analgesics.

2.heparin aspirin clopidrogel (I use LMWH but can use 'regular' unfractionated heparin.) Ideally pharmacokinetically give LMWH 3-4x daily. Most ppl can and will do bid-tid! Monitoring LMWH more difficult with bloods and UFH has more risks of bleeding. hey ho.

3.Oxygen enriched environment first 24 hours poss more if in CHF +/- frusemide if in CHF

4.min database sid incl renal values, electrolyes bid, I prefer running venous blood gases as costs the same a slytes on our istat gives me lytes + bunch more nfo about metabolic status

5.Physio and massage poss acupuncture to increase circulation after 1-2 days when less painful

6. Investigation of cardiac status and prognosis, preferably by someone used to scanning hearts!

I agree overall euthanasia is the BEST IF the owners are not

a) financially commited to spending +++

b) emotionally commited to the cat

c) willing to come in for regular checks exams and tests

d)aware things can go wrong at any stage and the cat prob wont live longer than a year

I have treated cats successfully with CHf for > 6 mo and withotu CHF > 1 year.

I am surprised to see people still advocating or performing surgical treatment of aortic thromboembolism in cats. I thought it was relegated to the annals of veterinary medicine's history and I remember reading about it from the 1960s with cool pics in B+W from the great Dr Buchanan!

I agree completely with David M - there has been shown to be NO improvement in outcome with either sugrical treatment or thrombolytic mechanisms in cats with this disease. Endovascular clot removal via rheolytic machines (very cool mechanism for those who are interested) has also shown NO benefits over conservative management. (http://www.ncbi.nlm.nih.gov/pubmed?term=rheolytic%20cat) I spoke to Mark Kittleson sometime ago who used this machine and ran the study - he does not recommend it.

As David said cats who present in CHF have lower survival.I think one needs to fully assess these cats via ultrasound - preferably by a cardiologist- is there still a clot in the LA? what is the underlying cardiac disease - in this case OP said no murmur which makes me more suspicious for RCM (often present without murmur and have a thrombus at first presentation) cf HCM (who may also not have a murmur but less likely to present like this first time cf RCM). RCM kitties have a poorer prognosis. Also need to evaluate the aorta and its branches.eg are there clots in the renal arteries? mesenteric vessels? Hoe big is the clot in the aorta and is the occlusion complete vs partial? Also useful to have US to follow progression of re-vascularisation tho less imp..

Re LA (left atrial) size as mentioned by DM- an excellent point- not a predictor- it is more about LA systolic function as well as Left auricular appendage velocities which are shown to be predictive of risk of thromboembolic disease in cats - I find it tough to do this doppler study the view is a bit skew-wiff (sp?) but is the only way (other than measuring LA motion in m mode or eyeballing it) of predicting risk in patients with cardiomyopathies.

As medical and surgical therapy carry equal outcomes, what is the benefit of major invasive surgery in an unstable cat potentially with CHF with all the attendant risks of reperfusion injury (which may heppen anyways, granted but rapid and much more likely with this procedure) - major welfare and ethical concern in my opinion.

would any of us go for this surgery on ourselves if the doc told us there is no greater chance of survival or improvement of the original disease if we we did the op vs not but you have all the increased risks of surgery anaesthesia and esp bleeding from the aorta?! I think not...

Re: cat with saddle thrombus

Hannah Wynne Richards — Fri, 20 Jul 2012 11:39:30 GMT

PS to above Maybe the heparin was to prevent further extension of the clot

Wynne

Re: cat with saddle thrombus

Hannah Wynne Richards — Fri, 20 Jul 2012 11:38:18 GMT

Until it was able to be transported I was in telephone contact daily with the Specialist-who approved of what I was doing

Wynne

Re: cat with saddle thrombus

Richard Fox — Fri, 20 Jul 2012 09:21:23 GMT

Heparin (from my molecular understanding) binds to Anti-thrombin III, which then inhibits thrombin thus preventing the conversion of fibrinogen to fibrin - fibrin being he major constituent of a clot. Thus once the fibrin has formed Heparin is as Matin said is pretty useless and also promotes haemorrhage - it is good at prevention though. That's why drugs like streptokinase (derived from bacteria) were used for thrombolysis. Newer drugs have been developed like alteplase, reteplase, or tenecteplase as some patients (humans) have hypersensitivities to SK - That's the limit of my knowledge.

Trouble is if you break up a clot too aggressively and quickly you may make multiple smaller clots that may cause more serious thrombosis in vital organs causing an infarct?

Re: cat with saddle thrombus

Martin Atkinson — Thu, 19 Jul 2012 17:11:04 GMT

[quote user="Hannah Wynne Richards"]Bold surgeons obviously prefer surgery I don't often see them but my last case was very successful I unblocked it with heparin [/quote] Doesn't common consent suggest that heparin does not/cannot act upon established clots and that it will only prevent further clotting? The clot busting drugs used in humans are not available/impractical for use in our patients. I feel your success was down to time and the cat's own body compensating. Not to say it was the wrong choice of treatment and I would use heparin and aspirin myself but not with any expectation that it would remove an existing clot.

Re: cat with saddle thrombus

Hannah Wynne Richards — Thu, 19 Jul 2012 11:21:12 GMT

I hadn't realised the onset of hyperkalaemia was that rapid-but since the animal would still be anaesthetised there would be no welfare implications and if the surgeon is sufficiently brave then at least it has a chance-which it doesn't with automatic euthanasia

I can't work out what you're advising David You say that if temp is over 37.2 there's a 50% chance of success with medical treatment You then say that euthanasia is the most welfare friendly option

I would always tell the owner that prognosis is grave but both my last case-it's years since the previous one-which was euthanised -and the OPs show that treatment can be successful-this cat seems (at the moment) to be responding As I said before-treat the individual

In private practice-costs are definitely a factor These are intensive care cases and if the owners are unable/unwilling to meet the considerable costs of doing this properly then I would agree that euthanasia is,sadly,the best option

Wynne

Re: cat with saddle thrombus

David Mills — Thu, 19 Jul 2012 11:00:49 GMT

[quote user="Julian Earl"]

Just out of interest... why 37.2? Not 37.3 or 37? Seems a bit specific. I've had animals (not thrombosis cases, just generally) with lower temperatures than that recover although I assume we'd all agree that the lower the temp, the poorer the prognosis. Is it from some study or personal observation?

[/quote]

http://www.ncbi.nlm.nih.gov/pubmed/12564730

Specifically for ATE - 50% probability of survival at 37.2 (drops sharply at temps below that). Largest case study yet into 127 cats. There are other parameters too.

Op/non op is nothing to do with cost, bravery, or otherwise. If offering the client this option then you should really have an estimate of likely success, certainly versus medical therapy. Medical therapy can carry a reasonable chance of functional return. Moreover there is no way of knowing if the leg is 'dead' from physical exam until reperfusion is achieved which is time dependent - making this 'case selection' argument null. The rise in K is rapid and fatal, usually before the cat leaves the table - very few of us can get K+ results in seconds so whilst I'm aware hyperK is treatable it may not be done successfully in this setting. The op in its current from is nothing more than experimental, and advised against in all texts; owners should be informed. It may be it does work but I think this something for experimenters to find out, not practitioners playing on peoples' hope or desperation, especially where there is a viable alternative.

Of course people have had cases that have done well. Its the whole point of dealing in median Sts so we can judge the most common outcome. To die or be affected by an ATE is excruciatingly painful, right up there with bone lysis. Personally I would advise clients that the projected increase in longevity (at what quality with a paretic leg or CHF?) is far outweighed by the welfare issues and the almost certainty of recurrence. Until prevention is proven to work or the disease can be treated with any element of surety of success, euthanasia represents the best most welfare-friendly outcome for all parties.