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A perilous cause for cardiogenic shock
  1. Suresh Madhavan,
  2. Gargi Sathish
  1. Department of Cardiology, Medical College, Kottayam, Kerala, India
  2. Department of Ophthalmology, Medical College, Kottayam, Kerala, India
  1. Correspondence to Dr Suresh Madhavan, Department of Cardiology, Medical College, Kottayam, Kerala 686008, India; drsureshmadhavan76{at}

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A 34-year-old man with no conventional coronary risk factors was admitted with inferoposterior and right ventricular myocardial infarction with evidence of cardiogenic shock. Patient was taken for emergency primary percutaneous coronary intervention. Because the patient was hemodynamically unstable, direct cannulation of right coronary artery was done, which showed ostioproximal thrombotic occlusion of right coronary artery. After wiring the vessel, thrombus aspiration and subsequent stenting was done. Thrombolysis in myocardial infaction (TIMI) III flow was observed with rapid stabilisation of haemodynamic parameters (figure 1A–C). On cannulating left main coronary artery, definite thrombus was observed in proximal left anterior descending artery and noted haziness suggestive of thrombus in proximal left circumflex artery. Thrombus aspiration was done in both vessels and TIMI III flow was observed in both vessels (figure 1D–F). Coronary angiography done 5 days after the primary angioplasty showed patent stent in right coronary artery and TIMI III flow in all coronary vessels and no evidence of thrombus or dissection. While recovering, patient disclosed heavy bout of cannabis usage 2 h prior to the event. Treadmill test done after 3 months of procedure was negative for inducible ischaemia. Cannabis has been the most widely used illicit drug worldwide. Cannabis-induced coronary dissection and thrombosis leading to myocardial infarction have been described.1 But primary percutaneous intervention in cannabis-induced multivessel coronary thrombus is not reported in the literature.

Figure 1

(A) Right coronary angiography showing thrombus causing ostioproximal obstruction; (B) thrombus aspiration being done in right coronary artery; (C) right coronary artery showing TIMI III flow after thrombus aspiration and stenting; (D) right anterior oblique (RAO) caudal view showing left main coronary artery bifurcating to left anterior descending coronary artery, both vessels showing thrombus; (E) RAO caudal magnified view showing thrombus in left anterior descending coronary artery and haziness in left circumflex artery  and (F) thrombus aspirated from the coronary vessels.


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  • Contributors SM and GS are equally involved in diagnosing and treating the patient. SM has made substantial contributions to the conception or design of the case report and the acquisition, analysis and interpretation of data. GS  has helped in drafting the article or revising it critically for important intellectual content.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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