A strong association of gemcitabine to acute coronary syndrome (ACS) is not currently established in the literature. In this series, we highlight that both patients with gemcitabine-related ACS were more than 50 years old, had underlying coronary artery disease and suffered from metastatic cancer. However, further prospective studies are required to validate the significance of these observations.

When considering rheumatoid arthritis (RA)-associated pulmonary diseases, interstitial lung disease and pleural disease are the most common RA-associated pulmonary manifestations while spontaneous pneumothorax and bronchopleural fistula (BPF) are among the extremely rare ones. To the best of our knowledge, all the previous reports of RA-associated BPFs were attributed to peripherally located pulmonary nodules that necrotized, burst into the pleural cavity, and eventually lead to the fistula formation. However, we hereby present the first case of BPF in an RA patient that formed in the absence of any underlying rheumatic pulmonary nodules. Additionally, our patient was on chronic methotrexate therapy, and there are no data in the literature that suggest methotrexate-induced parenchymal lung disease can predispose to BPF formation. Our report is the first to introduce a probe to further investigate this association.

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Pulmonary embolism (PE) remains one of the highest causes of cardiovascular mortality worldwide. Systemic thrombolysis for acute PE reduces cardiovascular collapse but has the potential to cause major complications, including intracranial hemorrhage, systemic hemorrhage, immunologic complications, hypotension, and myocardial rupture. Catheter-directed thrombolysis accompanied with high-frequency ultrasound reduces systemic dose, allows increased local dose, and expedites clot lysis at the site of embolism. Although rare, some patients may have a patent foramen ovale or other atrial septal defect (ASD) which cannot be visualized during fluoroscopy which may complicate this procedure. A 41-year-old diabetic smoker presented to the emergency department with hypoxia, tachycardia, and light headedness. Computed tomography angiography (CTA) of the chest revealed bilateral PE with right ventricular enlargement and right heart strain pattern. Transthoracic echocardiogram revealed right ventricular enlargement. He was diagnosed with submassive PE. He underwent right heart catheterization with two angled pigtail catheters manipulated through the right heart to reach the right and left pulmonary arteries, however on frontal fluoroscopy, the catheters appeared slightly more caudal than would be expected. Lateral fluoroscopy was performed which did not show the catheter going through the expected anterior curvilinear course of the right ventricle and pulmonary trunk. Contrast was injected into each pigtail catheter and this demonstrated retrograde flow of contrast back into the left atrium, confirming that the catheters were positioned in the pulmonary veins, having passed through an ASD. On review of CTA chest, there was a visible patent foramen ovale. Congenital heart defects are rare but can complicate certain procedures and interventionalists need to be aware of this possibility. Catheter position more caudal than the pulmonary artery silhouettes should alert the operator to the incorrect placement in the pulmonary veins through an ASD. In these circumstances, lateral fluoroscopy will show absence of the catheters along the expected anterior curvilinear route of the right ventricle, pulmonary infundibulum, and pulmonary trunk. Contrast injection will show centripetal flow back to the left atrium rather than the centrifugal flow away from the heart. Other potential confirmatory methods include pressure monitoring and blood gas sampling. In addition, careful scrutiny of the CT angiogram for an ASD before the procedure may alert the operator to this potential pitfall. The interventionalist must remain vigilant to unexpected anatomical variants to avoid potential harm.