clinical protocol 17

Treatment of thromboembolism
Thromboembolism refers to ischemia caused by acute obstruction of a blood vessel by a platelet aggregate.
The majority occur in the terminal aorta leading to ischaemia of the hind limbs, but they can affect any area of
the body. Most affected cats have underlying heart disease and recurrence is difficult to prevent and the
condition is usually extremely painful. For these reasons it is not unwise to consider euthanasia as a
treatment option in many cases. For the committed owner and in a cat that is not severely affected, treatment
involves intensive monitoring to combat complications such as congestive heart failure, unrelenting pain,
reperfusion injury and poor limb viability. Most cats require intensive hospitalisation and benefit from 24 hour
care.
Although there are no strict guidelines on prognosis, echocardiography can be helpful in determining the
severity of underlying cardiac pathology and whether gross thrombus formation is evident which might alter
decision making on progressing with treatment. A poor prognosis is usually expected with severe
hypothermia, hyperphosphataemia, refractory CHF, hyperkalemia, declining limb viability, severe left atrial
enlargement or myocardial failure. There is little data on the effectiveness of thrombolytics and drugs used in
prevention of this condition and many therapies have unproven effectiveness.

Treatment goals
Pain relief – as the condition is acutely painful, pain relief is paramount for the welfare of the cat. Route of
administration is important – ie, avoiding subcutaneous injections in dehydrated animals and ischaemic areas
for transdermal medications.

Manage congestive heart failure if present with diuretics or inotropic agents as appropriate.

General support – hydration and nutrition. Judicious iv fluids, tube feeding and warming. These cats have
poor collateral circulation and are non-ambulatory, so susceptible to skin burns; frequent turning is essential.

Thrombolysis – medical thrombolectomy is controversial. Drugs such as streptokinase and urokinase have
been associated with significant rates of acute mortality resulting from direct toxic effects of the drugs,
bleeding complications and reperfusion injury. Recombinant tissue-type plasminogen activator – (t-PA) is less
likely to cause bleeding complications, however, it is important to recognise that these drugs have side-
effects that require intensive monitoring, they are considerably expensive and their efficacy is not yet proven.

Limit new thrombus formation - Heparin can be given as unfractionated (traditional heparin) or low
molecular weight (fractionated) heparin – the latter is considerably more expensive. Efficacy data on these
drugs is minimal, however side effects are minimal.

Prevent repeated events - warfarin and other anticoagulants. The use of anticoagulants for prevention is still
controversial and there are no good long term studies validating the effectiveness of any anticoagulant in
cats. Warfarin therapy is variable between cats and expensive to monitor. It needs to be overlapped with
heparin for a number of days, and the PT time should be regularly checked to achieve a PT of 1.3 – 1.6 times
normal, or an INR of between two and three. Aspirin may be as effective/ineffective and given at 1mg/kg q24h
(low dose) has few side effects. This dose necessitates recompounding. Its effectiveness is still unproven.
Newer antiplatelet drugs have generally proven unrewarding in cats but this may change with the release of
new drugs. There is a small amount of evidence that pimobendan may inhibit platelet aggregation in cats but
this is still largely unproven in cats that are at risk of thromboembolism.

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