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CASE REPORT
Massive haemorrhage associated with inadvertent incision of a suspected carotid artery pseudoaneurysm in a cat A. W. Pfaff, E. A. Rozanski and A. M. Lynch Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA 01536, USA
A 12-year-old, castrated male, domestic long-haired cat experienced massive haemorrhage associated with an incision of a swelling on the neck 2 weeks after right-sided ventral bulla osteotomy. Emergent control of haemorrhage was gained through unilateral carotid artery ligation. Cardiopulmonary resuscitation was provided in conjunction with massive blood transfusion. The cat made an unremarkable recovery. Carotid artery pseudoaneurysm due to surgical disruption of the carotid artery during ventral bulla osteotomy, specifically through the use of self-retaining retractors, was suspected. This case highlights the development of pseudoaneurysm as a potential complication of head and neck surgery, and additionally describes a case of massive transfusion in a cat.
Journal of Small Animal Practice (2015) 56, 720–722 DOI: 10.1111/jsap.12372 Accepted: 13 April 2015; Published online: 27 May 2015
INTRODUCTION Carotid artery pseudoaneurysms (PAs) are rarely described in humans, and only one case report after traumatic venipuncture has been described in a cat (McCollum et al. 1979, Nicoucar et al. 2008, Nadig et al. 2009, Townsell et al. 2012, Bayarogullari et al. 2014). The most common reason for PA of the carotid system in humans is blunt or penetrating trauma. Iatrogenic causes such as femoral arterial catheterisation and penetrating trauma have also been reported. Non-traumatic causes include atherosclerosis, infection and fibromuscular dysplasia (McCollum et al. 1979, Nicoucar et al. 2008, Nadig et al. 2009, Bayarogullari et al. 2014). Carotid PAs do not appear to have previously been reported in association with surgical procedures in cats. Massive transfusion (MT) has been described in dogs (Jutkowitz et al. 2002). Retrospective studies regarding transfusion practices in cats including multiple transfusions exist, but MT due to arterial haemorrhage has not yet apparently been described in a cat (Klaser et al. 1999, Weingart et al. 2004, Roux et al. 2008).
CASE HISTORY A 12-year-old castrated male domestic long-haired cat, weighing 5 kg was presented for evaluation of lethargy, and a neck swelling that occurred 2 weeks after right-sided ventral bulla osteotomy (VBO). Three weeks before presentation the cat developed acute onset of severe right-sided peripheral vestibular disease. An MRI 720
scan of the head confirmed severe otitis interna/media. An ear swab for bacterial culture documented β-haemolytic Streptococcus sp, Methicillin-resistant Staphylococcus pseudintermedius and a multi-drug resistant Corynebacterium species. Antimicrobial therapy was instituted with chloramphenicol (Compounded chloramphenicol, Wedgewood pharmacy) 50 mg/kg orally twice a day based upon susceptibility testing results. Because of the severity of the clinical signs, a VBO was performed 7 days later. The surgical procedure was considered uneventful and anaesthesia was performed and monitored by a board-certified anaesthetist. There was no evidence of hypotension intraoperatively, and blood loss was considered minimal. Histopathology confirmed marked, diffuse, chronic, proliferative, neutrophilic and lymphohistiocytic otitis media. A left-sided oesophagostomy tube was placed for nutritional support. Laboratory testing prior to surgery had been unremarkable. The swelling was noticed 2 days prior to presentation, 12 days after the VBO was performed. On presentation, the cat was quiet, but responsive. The vestibular signs were unchanged with the remaining physical examination being unremarkable. The incision was slightly red. A 2-cm round fluid-filled swelling was present near the surgical side. Surgical exploration for drainage was planned, as the fluctuant swelling was considered most likely to be an abscess and there was concern that needle aspiration would not be sufficient to provide drainage. A pre-operative haematocrit was 0·3 L/L (reference interval; 0·37–0·50 L/L) and total solids were 80 g/L (reference interval 58–65 g/L). The cat was pre-medicated
Journal of Small Animal Practice
•
Vol 56
•
December 2015
•
© 2015 British Small Animal Veterinary Association
Massive haemorrhage in a cat
with buprenorphine (Buprenex, Rickett Coleman Products) (0·006mg/kg) intravenously (IV), and anaesthesia was induced with 2 mg/kg of ketamine (Ketamine Hydrochloride injection, Phoenix Scientific) and 4 mg/kg of propofol (Propoflo, Abbott Animal Health ) IV. Endotracheal intubation was performed with a 4 mm ID endotracheal tube and anaesthesia was maintained with 2% isoflurane (Isoflo, Abbott Animal Health) in oxygen. The cat was monitored with a multiparameter monitor (Passport Multiparameter monitor) that included capnography, pulse oximetry and continuous ECG. The swelling was explored with a 1·0 cm full thickness incision. A blood clot was removed, followed immediately by massive haemorrhage in pulsatile fashion. Direct digital pressure was applied, but haemostasis was not achieved. Cardiopulmonary arrest was identified by lack of palpable pulse, and absence of detectable end-tidal CO2. Isoflurane was discontinued and immediate fluid resuscitation begun with 10 mL/kg of lactated Ringer’s solution (Veterinary LR injection, Abbott Laboratories) and 4 mL/kg of 7·2% sodium chloride (7·2% sodium chloride, Butler Schein) IV. The incision was rapidly extended, enabling identification of the common carotid artery (CCA). The CCA was ligated in a simple circumferential manner with two 3-0 sutures (PDS II suture, Ethicon) which resulted in immediate control of the haemorrhage. Simultaneously while the CCA was being ligated, cardiopulmonary resuscitation was initiated. This involved basic life support measures (chest compressions at 100 compressions per minute and positive pressure ventilation at 12 breaths per minute) and the administration of 0·01 mg/kg of epinephrine (Epinephrine, Abbott Laboratories) IV. Return of spontaneous circulation ensued within 90 seconds. Three units (60 mL each) of type-specific (type A) feline stored whole blood were subsequently infused over 7 minutes. The cat of this report had been a blood donor in his youth, so his blood type was available in the medical record. The surgical site was monitored for bleeding for approximately 5 minutes before routine closure in two layers with 3-0 PDS. Estimated blood loss was approximately 220 mL based upon the weight of gauze sponges. Following return of spontaneous circulation, the cat was hypothermic (32·7°C), and remained intubated with intermittent assisted positive pressure ventilation for approximately 1 hour. The cat was admitted to the ICU and point of care testing (Nova Stat Profile, Nova Biomedical Corporation) at this time identified anaemia (HCT 0·15 L/L) and hypoproteinaemia (total protein 40 g/L), hyperglycaemia (16·1 mmol/L; reference interval 3·7–6·7 mmol/L), mild hyperlactataemia (2·2 mmol/L; reference interval
CASE REPORT
Massive haemorrhage associated with inadvertent incision of a suspected carotid artery pseudoaneurysm in a cat A. W. Pfaff, E. A. Rozanski and A. M. Lynch Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA 01536, USA
A 12-year-old, castrated male, domestic long-haired cat experienced massive haemorrhage associated with an incision of a swelling on the neck 2 weeks after right-sided ventral bulla osteotomy. Emergent control of haemorrhage was gained through unilateral carotid artery ligation. Cardiopulmonary resuscitation was provided in conjunction with massive blood transfusion. The cat made an unremarkable recovery. Carotid artery pseudoaneurysm due to surgical disruption of the carotid artery during ventral bulla osteotomy, specifically through the use of self-retaining retractors, was suspected. This case highlights the development of pseudoaneurysm as a potential complication of head and neck surgery, and additionally describes a case of massive transfusion in a cat.
Journal of Small Animal Practice (2015) 56, 720–722 DOI: 10.1111/jsap.12372 Accepted: 13 April 2015; Published online: 27 May 2015
INTRODUCTION Carotid artery pseudoaneurysms (PAs) are rarely described in humans, and only one case report after traumatic venipuncture has been described in a cat (McCollum et al. 1979, Nicoucar et al. 2008, Nadig et al. 2009, Townsell et al. 2012, Bayarogullari et al. 2014). The most common reason for PA of the carotid system in humans is blunt or penetrating trauma. Iatrogenic causes such as femoral arterial catheterisation and penetrating trauma have also been reported. Non-traumatic causes include atherosclerosis, infection and fibromuscular dysplasia (McCollum et al. 1979, Nicoucar et al. 2008, Nadig et al. 2009, Bayarogullari et al. 2014). Carotid PAs do not appear to have previously been reported in association with surgical procedures in cats. Massive transfusion (MT) has been described in dogs (Jutkowitz et al. 2002). Retrospective studies regarding transfusion practices in cats including multiple transfusions exist, but MT due to arterial haemorrhage has not yet apparently been described in a cat (Klaser et al. 1999, Weingart et al. 2004, Roux et al. 2008).
CASE HISTORY A 12-year-old castrated male domestic long-haired cat, weighing 5 kg was presented for evaluation of lethargy, and a neck swelling that occurred 2 weeks after right-sided ventral bulla osteotomy (VBO). Three weeks before presentation the cat developed acute onset of severe right-sided peripheral vestibular disease. An MRI 720
scan of the head confirmed severe otitis interna/media. An ear swab for bacterial culture documented β-haemolytic Streptococcus sp, Methicillin-resistant Staphylococcus pseudintermedius and a multi-drug resistant Corynebacterium species. Antimicrobial therapy was instituted with chloramphenicol (Compounded chloramphenicol, Wedgewood pharmacy) 50 mg/kg orally twice a day based upon susceptibility testing results. Because of the severity of the clinical signs, a VBO was performed 7 days later. The surgical procedure was considered uneventful and anaesthesia was performed and monitored by a board-certified anaesthetist. There was no evidence of hypotension intraoperatively, and blood loss was considered minimal. Histopathology confirmed marked, diffuse, chronic, proliferative, neutrophilic and lymphohistiocytic otitis media. A left-sided oesophagostomy tube was placed for nutritional support. Laboratory testing prior to surgery had been unremarkable. The swelling was noticed 2 days prior to presentation, 12 days after the VBO was performed. On presentation, the cat was quiet, but responsive. The vestibular signs were unchanged with the remaining physical examination being unremarkable. The incision was slightly red. A 2-cm round fluid-filled swelling was present near the surgical side. Surgical exploration for drainage was planned, as the fluctuant swelling was considered most likely to be an abscess and there was concern that needle aspiration would not be sufficient to provide drainage. A pre-operative haematocrit was 0·3 L/L (reference interval; 0·37–0·50 L/L) and total solids were 80 g/L (reference interval 58–65 g/L). The cat was pre-medicated
Journal of Small Animal Practice
•
Vol 56
•
December 2015
•
© 2015 British Small Animal Veterinary Association
Massive haemorrhage in a cat
with buprenorphine (Buprenex, Rickett Coleman Products) (0·006mg/kg) intravenously (IV), and anaesthesia was induced with 2 mg/kg of ketamine (Ketamine Hydrochloride injection, Phoenix Scientific) and 4 mg/kg of propofol (Propoflo, Abbott Animal Health ) IV. Endotracheal intubation was performed with a 4 mm ID endotracheal tube and anaesthesia was maintained with 2% isoflurane (Isoflo, Abbott Animal Health) in oxygen. The cat was monitored with a multiparameter monitor (Passport Multiparameter monitor) that included capnography, pulse oximetry and continuous ECG. The swelling was explored with a 1·0 cm full thickness incision. A blood clot was removed, followed immediately by massive haemorrhage in pulsatile fashion. Direct digital pressure was applied, but haemostasis was not achieved. Cardiopulmonary arrest was identified by lack of palpable pulse, and absence of detectable end-tidal CO2. Isoflurane was discontinued and immediate fluid resuscitation begun with 10 mL/kg of lactated Ringer’s solution (Veterinary LR injection, Abbott Laboratories) and 4 mL/kg of 7·2% sodium chloride (7·2% sodium chloride, Butler Schein) IV. The incision was rapidly extended, enabling identification of the common carotid artery (CCA). The CCA was ligated in a simple circumferential manner with two 3-0 sutures (PDS II suture, Ethicon) which resulted in immediate control of the haemorrhage. Simultaneously while the CCA was being ligated, cardiopulmonary resuscitation was initiated. This involved basic life support measures (chest compressions at 100 compressions per minute and positive pressure ventilation at 12 breaths per minute) and the administration of 0·01 mg/kg of epinephrine (Epinephrine, Abbott Laboratories) IV. Return of spontaneous circulation ensued within 90 seconds. Three units (60 mL each) of type-specific (type A) feline stored whole blood were subsequently infused over 7 minutes. The cat of this report had been a blood donor in his youth, so his blood type was available in the medical record. The surgical site was monitored for bleeding for approximately 5 minutes before routine closure in two layers with 3-0 PDS. Estimated blood loss was approximately 220 mL based upon the weight of gauze sponges. Following return of spontaneous circulation, the cat was hypothermic (32·7°C), and remained intubated with intermittent assisted positive pressure ventilation for approximately 1 hour. The cat was admitted to the ICU and point of care testing (Nova Stat Profile, Nova Biomedical Corporation) at this time identified anaemia (HCT 0·15 L/L) and hypoproteinaemia (total protein 40 g/L), hyperglycaemia (16·1 mmol/L; reference interval 3·7–6·7 mmol/L), mild hyperlactataemia (2·2 mmol/L; reference interval
