Pulmonary

Thromboembolism
Emily S. Southward DVM
University of Missouri Columbia
Veterinary Medical Teaching
Hospital

Definition
Pulmonary

thromboembolism

One clot or many clots that form at

distant sites and lodge in the pulmonary
vasculature.
Pulmonary

artery thrombus

Clots that form in the pulmonary

vasculature.
Clots

can partially or fully occlude

pulmonary vessels.

Virchows Triad
Venous

stasis.
Injury or abnormalities to the vessel
wall.
Alterations in coagulation properties.

Venous Stasis
Accumlation

of activated
procoagulants.
Immobilization
Inadequate cardiac pump.

Promotes

thrombus formation.

Vessel Wall Injury

Acute

or chronic injury to vessel

endothelium.
Leads to activation of platelets and
clotting cascade.
Promotes thrombus formation.

Vessel Injury

Platelet Adhesion

Aggregation

Alternations in Coagulation
Increase

in procoagulant factors.

By trauma to vascular wall or

extravascular tissues.
Releases tissue thromboplastin and
phospholipid.
Leads to formation of prothrombin
activator.
Prothrombin Thrombin

Alterations in Coagulation
Decrease

in anticoagulant factors.

Thrombomodulin
Antithrombin III
Heparin
Alpha2-Marcoglobulin
Plasmin
Leads

to hypercoagulable state by
formation of thrombin.

Thrombosis Formation
Platelet

nidus at site of injury.

Growth by aggregation of platelets
and fibrin.
Activation of clotting cascade.
Larger growth to a red fibrin
thrombus.
Thrombus fractures and embolizes to
other areas of the body.

Predisposing Factors or Diseases

for Development of PTE
Hypercoagulable

state

Nephrotic syndrome
Immobilization
Amyloidosis
Early DIC
Hyperadrenocorticism

Capillary

fragility
Activation of clotting cascade.

Predisposing Factors or Diseases

for Development of PTE
Hypercoagulable
Capillary

fragility

state

Diabetes Mellitus
Immunemediated hemolyitc anemia
Sepsis
Hyperadrenocorticism

Activation

of clotting cascade.

Predisposing Factors or Diseases

for Development of PTE
Hypercoagulable
Capillary

state

fragility
Activation of clotting cascade.
Sepsis
Pneumonia/pyothorax
Heartworm disease
Surgery
Bacterial endocarditis
Neoplasia

Consequences of PTE
Respiratory.

Increased alveolar dead space.

Hyperventilation.
Hypoxemia.
Ventilation/perfusion inequality.
Intrapulmonary shunts.

Normal Alveolus

Increased Alveolar Dead Space

Hypoxemia
Results

from ventilationperfusion inequality, physiologic

shunting and increased dead
space.

Intrapulmonary Shunts
Blood

that has not been to areas of

ventilated lung and enters systemic
circulation without gas exchange
taking place.
Poorly oxygenated blood enters the
arterial system lowering the PaO2.
Not responsive to oxygen therapy.

Ventilation/Perfusion Inequality
V/Q

inequality occurs when

distribution of blood is altered to the
alveoli.
O2 increase in the alveoli and CO2
decreases.

Hemodynamic Changes
Increase

in pulmonary vascular
resistance.
Increased afterload to the right
heart.
Can lead to circulatory collapse and
shock.

Clinical Signs
Not

pathognomonic.

Dyspnea.
Tachypnea.
Hemoptysis.
Tachycardia.
Hypoxemia.
Sudden death.

Diagnosis
CBC/Biochemistry

results reflect
primary disease process.
Hypoxemia common but 10% of
patients are normal.
Thoracic radiographs can be normal
and inconclusive.

LaRue MJ and Murtaugh RJ. Pulmonary

Thromboembolism in Dogs:47 cases (1986-87). J
Amer Vet Med Assoc. 1990 Nov. 15;197(1):13681372.
Johnson LR et al. Pulmonary Thromboembolism in
29 dogs:1985-1995 J Vet Intern Med. 1999
Jul;13(4):338-345.
Flkiger MA and Gomez JA. Radiographic Findings
in Dogs with Spontaneous Pulmonary Thrombosis
or Embolism. Veterinary Radiology, Vol.25,No.3
124-131.

Advanced Diagnostics
Pulmonary

scintigraphy
Pulmonary angiography.

Pulmonary Scintigraphy
Noninvasive
Aids

in diagnosis of PTE but not

definitive.
Two types- ventilation and perfusion
scans.

Perfusion Scan
Performed first.
Normal study rules
out PTE.
Radionuclidelabelled,
macroaggregated
albumin in
peripheral vein.

Ventilation Scan
Inhaled radioactive
inert gas-senon133 or technetium99m.
Patient under
general anesthesia.
Normal in PTE.

Ventilation/Perfusion Combo
With PTE the
ventilation scan
would be normal
and the perfusion
scan abnormal.
Suggestive of PTE.F

Picture from
WWW.bschsys.org/DiagnositcImaging/nucmd
/htm

Normal Human Perfusion Scan

Abnormal Human Perfusion

Scan

Pulmonary Angiography
Performed

if definitive diagnosis or
exclusion of PTE is required.
Requires sedation or general
anesthesia.
Greater risks.
Intraluminal filling defect and sharp
cutoff are diagnostic for PTE.

Pulmonary Embolus
Human lung.
Arrow indicates
abrupt termination
of a pulmonary
artery.

Www.brighamrad.Harvard.edu/cases/b
wh/images.

Treatment
Oxygen

therapy.
Heparinization 200-300 units/kg
subcutaneously every 8 hours.
Streptokinase or TPA.
Mechanical ventilation.
Long term- warfarin therapy.

Monitoring
Clotting

times- want to maintain PTT

at 1.5-2.5 times normal or and ACT
at 1.2-1.4 times normal.
Serial arterial blood gas analysis.
Respiratory rate.
Central venous pressure.
All other basic monitoring.

Complications Of Therapy
Hemorrhage

most common.
Not predictable.
Protamine therapy indicated with
hemorrhage due to heparin.
Vitamin K or fresh-frozen plasma in
warfarin therapy.

Prognosis
Guarded.
Improves

with early detection and

treatment.
Improves each day the patient
survives.
At risk for more emboli.

UMC VMTH Cases

Three

in data base.

Sadie
Magnum
Koko

Sadie Bailey
8-year-old

FS mixed breed dog.

Presented for weight loss, anemia,
and anorexia.
Weak and lethargic on presentation
Hemoabdomen, thrombocytopenia,
and neutrophilia with left shift.
Developed severe dyspnea and
ventricular tachycardia.

Sadies Thoracic Films

Sadies Thoracic Films

Sadies Necropsy
Hepatocellular

carcinoma
Adrenocortical hyperplasia
Pulmonary thrombois most lobar
branches effected.
Renal infarction.

Magnum Meeks
8-year-old

MC doberman pinscher
Presented for dyspnea of two days
duration.
Protein losing nephropathy.

Magnums Thoracic Films

Magnums Thoracic Films

Koko Westerhoff
12-year-old

FS dachshund.
Presented for lethargy, anorexia,
tachypnea, and possible CHF.
History includes diabetes mellitus,
IVDD and cataracts.
PE- Increased BV lung sounds, mild
crackles, tachycardia, and left
systolic murmur.

Kokos Thoracic Films

Kokos Thoracic Films

Kokos Pefusion Scintigraphy

Kokos Pefusion Scintigraphy

Kokos Necropsy
Muliple

small thrombi in the

pulmonary vasculature.
Cardiomegaly

Thanks
Dr.

Mann
Dr. Dodam
Dr. Lattimer
Dr. Kunz

Questions?