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CC BY 4.0 · Handchir Mikrochir Plast Chir
DOI: 10.1055/a-2739-3810
Fallbericht

Late-Onset Digital Ischaemia after WALANT: Successful Reversal with Off-Label Urapidil

Article in several languages: English | deutsch

Authors

  • Andrea Frey

    1   Hand Surgery, Kantonsspital Basel, Basel, Switzerland

  • Lukas Mathys

    1   Hand Surgery, Kantonsspital Basel, Basel, Switzerland

  • Christine Kammerhofer

    1   Hand Surgery, Kantonsspital Basel, Basel, Switzerland
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Abstract

Background

WALANT (Wide Awake Local Anaesthesia No Tourniquet) has revolutionised hand surgery by enabling procedures with a combination of lidocaine and epinephrine, thereby eliminating the need for sedation or a tourniquet. Although epinephrine is now considered safe in low concentrations, rare ischaemic complications may still occur.

Case Report

This report concerns a 74-year-old woman who developed delayed-onset digital ischaemia after WALANT-assisted excision of a Dupuytren’s nodule. Phentolamine, the standard reversal agent, was unavailable. Local infiltration with urapidil (12.5 mg), a selective α₁-adrenergic antagonist, rapidly restored perfusion and sensation. The patient recovered fully without sequelae.

Conclusion

This case highlights a rare but critical complication of WALANT. Urapidil may represent a safe and effective alternative to phentolamine in the management of epinephrine-induced vasospasm.

Keywords

WALANT - digital ischaemia - urapidil - epinephrine - hand surgery


Publication History

Received: 01 September 2025

Accepted: 20 October 2025

Article published online:
11 December 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References/Literatur

  • 1 Lalonde D. Wide awake local anaesthesia no tourniquet technique (WALANT). BMC Proc 2015; 9: A81
    Search in Google Scholar
  • 2 Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg 2001; 108: 114-124
    Search in Google Scholar
  • 3 McKee DE, Lalonde DH, Thoma A. et al. Achieving the optimal epinephrine effect in wide awake hand surgery. Hand (N Y) 2015; 10: 613-615
    Search in Google Scholar
  • 4 Degreef I, Lalonde DH. WALANT surgery of the hand: state of the art. EFORT Open Rev 2024; 9: 349-356
    Search in Google Scholar
  • 5 Nodwell T, Lalonde D. How long does it take phentolamine to reverse adrenaline-induced vasoconstriction?. Can J Plast Surg 2003; 11: 187-190
    Search in Google Scholar
  • 6 Zhu AF, Hood BR, Morris MS. et al. Delayed-onset digital ischemia after local anesthetic and low-dose epinephrine use. J Hand Surg Am 2017; 42: e19-e22
    Search in Google Scholar
  • 7 Dooley M, Goa KL. Urapidil. A reappraisal of its use in the management of hypertension. Drugs 1998; 56: 929-955
    Search in Google Scholar
  • 8 van Zwieten PA. Pharmacologic profile of urapidil. Am J Cardiol 1989; 64: 1D-6D
    Search in Google Scholar
  • 9 Schad H, Heimisch W, Baur R. et al. Effect of urapidil on ischemic myocardium in anesthetized dogs. Basic Res Cardiol 1990; 85: 270-278
    Search in Google Scholar
  • 10 Lalonde DH. Latest advances in wide awake hand surgery. Hand Clin 2019; 35: 1-6
    Search in Google Scholar
  • 11 Garrido AM, Ghaffari A. Urapidil in the management of hypertension: a review. Curr Hypertens Rep 2018; 20: 23
    Search in Google Scholar
  • 12 Swissmedic. Urapidil Stragen i.v. 50 mg/10 mL, solution injectable: Out-of-stock and pricing information. 2024
    Search in Google Scholar