A patient developed hemopericardium shortly after left brachial arterial embolectomy using an embolectomy catheter. Evaluation disclosed evolving pseudoaneurysm of the right coronary artery that was successfully managed by stenting. Misplacement of the embolectomy catheter within the coronary vessel was facilitated by an anomalous origin of the right coronary artery. This complication highlights the importance of correct insertion of the embolectomy catheter using the markers to avoid maladvancement and damage to central vessels.

We present a patient who was admitted for carotid endarterectomy due to tight carotid stenosis and recent amaurosis fugax. His medical history included significant coronary artery disease with stable angina pectoris, hypertension with wide pulse pressure, chronic renal failure, and anemia. During preparation for surgery, the patient developed type 2 myocardial infarction with prolonged chest pain, ST depressions on electrocardiogram, and significant troponin elevations. The patient posed a serious clinical dilemma whether to continue with surgery despite the type 2 myocardial infarction or postpone the surgery. We discuss the diagnostic tests and the decision-making processes that guided us in the preoperative period.

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Synthetic marijuana use has been reported in the last years as a possible causative factor of different cardiovascular events, including myocardial infarction, ischemic stroke, intracranial bleeding, and cerebral vasospasm. One case of aortic thrombosis was also reported, but that was in a patient using cocaine and synthetic marijuana together. A case of lower limb thromboembolism and synthetic marijuana use has not been reported to date. Intoxication, material impurity, blood vessel reactivity, and chemical interaction with other drugs have been proposed as possible mechanisms of these events.Methods: A 45-year-old woman arrived at the emergency department because of acute left leg ischemia. She was previously known to suffer from schizophrenia, obesity, and active smoking. She complained of pain that started suddenly 4 days before her admission and worsened that day. Pronounced ischemia and a mild neurologic deficit were found. Computed tomography angiography demonstrated an infrarenal aortic posterior wall thrombus, remnants of thrombus in both common iliac arteries, occlusion of the left distal popliteal artery, and patent tibialis posterior artery from the upper third of the calf feeding all three tibial arteries from above the ankle and into the foot. Bedside echocardiography demonstrated a small patent foramen ovale with no signs of other embolic sources. The patient refused hospitalization and intervention and was prescribed enoxaparin sodium (Clexane) on discharge. She was readmitted to the emergency department 3 days later because of worsening of the pain and associated neurologic deficit (both motor and sensory). Repeated anamnesis revealed a >10-year addiction to synthetic marijuana (Mr Nice Guy). Because of the neurologic deficit, the chosen treatment approach was open thromboembolectomy and angiography. Palpable peripheral pulses were achieved, but thrombosis recurred after a short time. Reinterventions included selective tibial artery thromboembolectomy, intra-arterial thrombolysis, arteriography, and administration of anticoagulation and antiaggregation medications.Results: Despite all attempts, rethrombosis and worsening of the ischemia led to the miserable result of amputation of the leg. Additional workup including transesophageal echocardiography and hematologic testing for hypercoagulation did not reveal any other causative factor.Conclusions: Synthetic marijuana should be considered a risk factor for thromboembolic events, the mechanism of which is still unknown.