An animal model of coronary thrombosis and thrombolysis--comparisons of vascular damage and thrombus formation in the coronary and femoral arteries after balloon angioplasty

2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 6: Defining rational use of thrombolytics

OBJECTIVES

To systematically review available evidence and establish guidelines related to the use of thrombolytics for the management of small animals with suspected or confirmed thrombosis.

DESIGN

PICO (Population, Intervention, Control, and Outcome) questions were formulated, and worksheets completed as part of a standardized and systematic literature evaluation. The population of interest included dogs and cats (considered separately) and arterial and venous thrombosis. The interventions assessed were the use of thrombolytics, compared to no thrombolytics, with or without anticoagulants or antiplatelet agents. Specific protocols for recombinant tissue plasminogen activator were also evaluated. Outcomes assessed included efficacy and safety. Relevant articles were categorized according to level of evidence, quality, and as to whether they supported, were neutral to, or opposed the PICO questions. Conclusions from the PICO worksheets were used to draft guidelines, which were subsequently refined via Delphi surveys undertaken by the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) working group.

RESULTS

Fourteen PICO questions were developed, generating 14 guidelines. The majority of the literature addressing the PICO questions in dogs is experimental studies (level of evidence 3), thus providing insufficient evidence to determine if thrombolysis improves patient-centered outcomes. In cats, literature was more limited and often neutral to the PICO questions, precluding strong evidence-based recommendations for thrombolytic use. Rather, for both species, suggestions are made regarding considerations for when thrombolytic drugs may be considered, the combination of thrombolytics with anticoagulant or antiplatelet drugs, and the choice of thrombolytic agent.

CONCLUSIONS

Substantial additional research is needed to address the role of thrombolytics for the treatment of arterial and venous thrombosis in dogs and cats. Clinical trials with patient-centered outcomes will be most valuable for addressing knowledge gaps in the field.

In vivo models for the evaluation of antithrombotics and thrombolytics

The development and application of animal models of thrombosis have played a crucial role in the discovery and validation of novel drug targets and the selection of new agents for clinical evaluation, and have informed dosing and safety information for clinical trials. These models also provide valuable information about the mechanisms of action/interaction of new antithrombotic agents. Small and large animal models of thrombosis and their role in the discovery and development of novel agents are described. Methods and major issues regarding the use of animal models of thrombosis, such as positive controls, appropriate pharmacodynamic markers of activity, safety evaluation, species specificity, and pharmacokinetics, are highlighted. Finally, the use of genetic models of thrombosis/hemostasis and how these models have aided in the development of therapies that are presently being evaluated clinically are presented.

A Simple, Reproducible Animal Model of Arterial Occlusion with Mixed Thrombus

Background: Current animal models of thrombotic arterial occlusion are complex and difficult to perform. A more simplified model of thrombotic occlusion with angiographic endpoints and mixed thrombotic composition would be useful to assess the effectiveness of new therapeutic modalities. Methods and results: Femoral arteries in 38 New Zealand White rabbits were cannulated. The animal protocol involved denudation of one iliac artery by stripping with progressively increasing balloon size, followed by inflow arterial occlusion and the addition of thrombin. Cineangiography was performed at baseline and 10 minutes after the procedure to assess TIMI blood flow. Baseline angiography revealed normal TIMI 3 flow in all arteries. A successful angiographic endpoint of TIMI 0 or TIMI 1 blood flow was achieved in only 6 or 46% of 13 rabbits with initial use of the protocol, but was successful in 25 or 100% of a consecutive series of rabbits after the initial or repeat use of the protocol. Importantly, histologic analysis of thrombus revealed a mixture of platelets, erythrocytes, and fibrin. The mean injury index of the internal elastic lamina (IEL) was 40.7 +/- 35.16%. No correlation was found between TIMI flow change and intact IEL (R = -0.068, p > 0.5). Total procedure time was about 1 hour. Conclusion: This simple and reproducible animal model of arterial occlusion provided a mixed thrombus that is comparable to human thrombus and thus may be useful to assess thrombolytic agents or new coronary interventional devices.

The double-tuck model: a new animal model of arterial thrombosis

PURPOSE

To develop an animal model of a fibrin- and platelet-rich intraluminal arterial thrombus with abnormal mural substrate to simulate in situ thrombosis of human atherosclerotic arteries.

MATERIALS AND METHODS

Parallel studies of the crush-thrombin model (CT) and double-tuck model (DT) were performed and evaluated with use of angiography and histologic analysis. Ten Yorkshire swine (1-6 months; 20-30 kg; 10 females) underwent right femoral and carotid cutdowns performed after administration of general anesthesia (4 mL intravenous thiopental sodium, isoflurane 2% in 1 L of oxygen). After angiography, the CT model was created in the left carotid artery and the DT model was performed in the right carotid artery. Angiograms were obtained at 20 minutes (n = 1), at 1 hour (n = 3), at 2 hours (n = 4), and at 3 hours (n = 2) before sacrifice. After sacrifice, histologic specimens were stained with hematoxylin-eosin (H-E stain) and phosphotungstic acid hematoxylin for fibrin. The specimens were examined for endothelial irregularity and adhesion, platelet aggregation, fibrin layering, vessel wall injury, and adventitial hemorrhage. The findings were quantified as 0 = absent, 1+ = slight, 2+ = moderate, and 3+ = severe.

RESULTS

Angiographic results were similar. However, histologic analysis of the CT model showed severe damage to the arterial wall with dissection in nine of 10 animals. In the DT model, no dissection was found (n = 10). Endothelial irregularity was found in six of 10 arteries treated with the CT method, as compared with nine of 10 arteries prepared with the DT model; endothelial adhesion was found in five DT arteries and in four CT arteries. Platelet aggregation was present equally in both methods. A fibrin- and platelet-rich thrombus was created in five of 10 examined arteries by both methods.

CONCLUSIONS

The DT model creates endothelial irregularity leading to formation of a platelet- and fibrin-rich thrombus, adherent to the vessel wall without damage to the media. This contrasts with the CT method, which created medial dissection in nine of 10 arteries. One hour is the minimum time required to produce a good quality thrombus; 2 hours is the optimum time. The DT model is proposed as a useful tool in the development of new devices, drugs, and biotechnologic advances.

Experimental models of chronic lower extremity arterial occlusive disease: lessons for drug development

Peripheral vascular disease is the result of chronic vascular insufficiency. As the vascular insufficiency of the lower limbs progressively deteriorates, the condition progresses from intermittent claudication (pain upon exercise) to pain at rest and gangrene. In very severe cases amputation of the leg may be necessary. Whilst dieting, cessation of smoking and physical exercise all beneficially affect the progression of the disorder, the available drug therapy is of limited benefit. Very effective pharmacological agents capable of alleviating the symptoms of chronic peripheral vascular disease have not been developed. In order to mimic the vascular insufficiency of intermittent claudication, an animal model was developed in rats. This involves short-term and long-term 6-10 weeks ligation of the femoral artery of the rat. As demonstrated using measurements of hindlimb skeletal muscle, blood flow, pO2, metabolism and function, a model of intermittent claudication was produced. Using this model, the beneficial effects of physical training was demonstrated. Physical training induced an increase in blood flow and a greater capacity for aerobic metabolism in the partially ischaemic skeletal muscle. The effect of vasodilators has also been examined in this model; in contrast to agents such as Ca2+ antagonists, K+ channel openers appear to improve nutritional blood flow and metabolism in the afflicted skeletal muscle. This model can also be utilized to demonstrate the effects of haemorrheological interventions and of agents modulating muscle metabolism. However, additional effort is required to develop models for the evaluation of efficacy of antiatherothrombotic drugs.