Median arcuate ligament syndrome is a rare and poorly understood condition that can have a significant impact on the quality of life of patients. Diagnosis is often difficult and delayed because of the need to exclude other pathologic processes. Treatment strategies traditionally involve open or laparoscopic division of the median arcuate ligament, with or without vascular reconstruction. This report portrays a case of median arcuate ligament syndrome with compression of two visceral arteries and distal embolic complications. A novel hybrid technique is described using intravascular ultrasound technology to aid in laparoscopic median arcuate ligament division. This allowed real-time intravascular visualization of the compressive segment, guided release of the ligament fibers, and demonstrated confirmation of decompression. (J Vasc Surg Cases and Innovative Techniques 2020;6:147-51.)

Recreational drug use is a recognized cause of a number of acute vascular events. Cocaine is associated with a number of cardiovascular diseases, including myocardial ischemia, arrhythmias, and aortic dissection. Cutting agents are commonly used to dilute the amount of cocaine required to enhance the profits of the seller. Such cutting agents themselves often provoke acute vascular disease. We present the case of a 34-year-old female presenting with profound ischemia affecting all four limbs secondary to cocaine inhalation.

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