Marijuana and Peripheral Vascular Disease: Pathophysiology, Clinical Evidence, and Cardiovascular Implications

Cannabis (marijuana) is increasingly used worldwide, driven by legalization and shifting public perception. Although often considered harmless, growing evidence suggests potential cardiovascular risks, including its association with peripheral vascular disease, particularly peripheral artery disease (PAD). This narrative review explores the emerging link between cannabis use and peripheral vascular disease by examining biological mechanisms and clinical data. The primary psychoactive compound, Δ9-tetrahydrocannabinol, interacts with the endocannabinoid system-especially cannabinoid receptor type 1 on endothelial and vascular smooth muscle cells-to promote oxidative stress, inflammation, vasoconstriction, and endothelial dysfunction, all of which may accelerate atherosclerosis and PAD. Clinical reports have documented cases of cannabis arteritis resembling thromboangiitis obliterans in young users, and population-based studies have shown significantly increased odds of PAD in marijuana users, even after adjusting for confounding factors. Furthermore, cannabis use is associated with acute cardiovascular events such as myocardial infarction, arrhythmias, and ischemic stroke, often in young individuals without traditional risk factors. The presence of potent synthetic cannabinoids or co-use of tobacco may further amplify these risks. Despite these findings, cannabis is often excluded from cardiovascular risk assessments, and public health surveys reveal a low perception of its harm. Given the expanding legalization and use of cannabis, clinicians should routinely inquire about cannabis use, particularly in younger patients presenting with vascular symptoms or events. While causal relationships remain under investigation, existing data highlight the importance of awareness, risk stratification, and further research into the vascular consequences of cannabis exposure.