Cocaine-induced Type-A Aortic Dissection Extending to the Common Iliac Arteries.

Aortic dissection is a rare and fatal complication of cocaine-induced hypertension. The injury mechanism is through shear stress that penetrates the intimal vessel layer, allowing blood flow to separate intimal and medial layers. Due to its scarcity and the paucity of related literature, our knowledge of this condition is limited. We present a rare case of a cocaine-induced aortic dissection, which extended continuously from the aortic root to the common iliacs, along with a literature review of similar cases. A 48-year-old male with recent cocaine use presented with left-sided chest-pain, which radiated to the back with nausea, diaphoresis, and shortness of breath. The patient was hypotensive. The initial radiographs and computed tomography were negative. The cardiac enzymes were elevated and the patient was admitted to rule out acute coronary syndrome. Next day echocardiogram and computed tomography revealed a Type-A aortic dissection continuously extending from the aortic root to the left common iliac artery. The patient was immediately transferred for surgery. Postoperatively, he developed acute kidney injury and shock liver. The patient status continued to deteriorate and he expired on postoperative day four. This case demonstrates the importance of prompt and thorough diagnostic evaluation, despite subjective history and initially negative imaging that might point towards other conditions. Unlike the previous cases, our case failed to identify the positive history of cocaine until nearly 24 hours into the patient's hospital course, suggesting a need for close monitoring in these patients and a possible need for repeat imaging.​​​​​​​.

Penetrating Obturator Artery Injury after Gunshot Wounds: A Successful Multidisciplinary Trauma Team Approach to a Potentially Lethal Injury.

Obturator artery injury (OAI) from pelvic gunshot wounds (GSW) is a rarely reported condition. Hemorrhages from pelvic trauma (PT) are mostly venous. Arterial hemorrhages represent about 10-20% of PTs. When arterial hemorrhages from PT occur, they are a severe and deadly complication often causing significant hemodynamic instability and eventual shock. A 23-year-old male presented to our emergency service via a private vehicle with multiple gunshot wounds to both thighs and to the lower back, resulted in rectal and obturator artery (OA) injuries. The patient underwent a successful coil-embolization of the right OA. Given the density of structures within the pelvis, patients who sustain gunshot wounds to the pelvic region are at high risk for injury to the small bowel, sigmoid colon, rectum, bladder, and/or vascular structures. While bleeding is the major cause of early mortality in PT, rectal injuries carry the highest mortality due to visceral injuries. A high clinical index of suspicion is needed to diagnose an iliac artery injury or injury to its branches. Prompt computed tomographic angiogram (CTA) and embolization of the OA is the best method to control and stop the bleeding and improve the mortality outcome. Clinicians caring for patients presenting with pelvic gunshot wounds should pay attention to the delayed presentation of internal hemorrhage from the OAs. A multidisciplinary team approach is crucial in the successful management of penetrating injuries to the obturator artery.