LEA 25. Pediatric Penetrating Injury of Popliteal Fossa

Abstract

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.