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Case Report
Accidental Intra-Arterial Injection of a Drug in a Patient
with Radial Artery Variation; A Rarity Leading to a Disaster
Joel Arudchelvam, Amanthana marasinghe
Consultant Vascular and Transplant Surgeon, Teaching Hospital Anuradhapura, Sri Lanka
*
Corresponding author: : Joel Arudchelvam, Consultant Vascular and Transplant Surgeon, Teaching Hos-
pital Anuradhapura, 14, 4/9, 37th Lane, Wellawatte, Colombo 6, Sri Lanka, Tel: 0094 775 409765; E-mail:
joelaru@yahoo.com
Received: 19 November, 2019; Accepted: 29 November, 2019; Published: 02 December, 2019
Abstract
Accidental intra-arterial injection in medical practice is
rare but results in thrombosis and loss of digits or the limb.
Variations in arterial anatomy predispose to accidental
cannulation and injection. We report such a patient who
presented to the Teaching Hospital Anuradhapura (THA)
Sri Lanka following intra-arterial cannulation and injection
of an antibiotic. This patient had an anatomical variation of
the radial artery (Superficial Radial Artery - SRA) which was
cannulated and injected with antibiotic resulting in radial
arterial thrombosis and digital gangrene.
Keywords: Intra-Arterial Injection; Arterial variation;
Superficial Radial Artery.
Abbreviations: THA - Teaching Hospital Anuradhapura,
Sri Lanka; SRA - Superficial Radial Artery; CPDA - Common
Palmar Digital Arteries; PDA - Proper Digital Arteries; SPB
- Superficial Palmar Branch; CTA - Computed Tomographic
Angiography
Introduction
Variations in the Radial Artery occur at a rate of 4.3% - 9%
[1,2]. Superficial Radial Artery (SRA) occurs at a rate of 0.5%
– 1% [3,4]. Radial and ulnar arteries form the superficial and
deep palmar arches in the hand. The Common Palmar Digital
Arteries (CPDA) arise from the Superficial Palmar Arch (SPA)
from which Proper Digital Arteries (PDA) arise to supple the
fingers. We report a patient who had an accidental injection
of an antibiotic into a superficial variant of the radial artery
(SRA) resulting in thrombosis of the radial artery resulting
in finger gangrene.
Journal of Clinical Case Reports and Case Studies
Volume 2019; Issue 2
Arudchelvam J, et al
Case Report
36 year old female presented with breast abscess which
was drained and antibiotic was administered through a
cannula inserted at the left distal forearm. The cannula was
inserted at a common cannulation site at the distal forearm
(where the Cephalic Vein is usually present at the radial
aspect of the distal forearm).
An antibiotic (Amoxicillin / Clavulanic acid) was injected
through the cannula. Immediately after injection the patient
felt intense burning sensation at the site of injection radiating
distally into the fingers. And the fingers became cyanosed.
Patient had intense pain on the tip of all fingers. Saturation
was not recordable with the pulse oximeter. The cannula was
removed and anticoagulation was started, and the patient
was transferred to the Teaching Hospital Anuradhapura for
vascular surgical management. At the time of presentation to
the Teaching Hospital Anuradhapura patient had cyanosed,
cold and painful fingertips. The radial pulse was not palpable
but the ulnar pulse was palpable. Examination revealed a
tender cord like structure along the radial border of the distal
forearm (thrombosed abnormal radial artery - SRA). Duplex
ultrasound scan showed it was a thrombosed artery which is
a direct superficial continuation of the radial artery running
along the radial border of the forearm and entering the
palmar space through the first inter metacarpal space. Before
becoming superficial it gave off Superficial Palmar Branch
(SPB). The anticoagulation with unfractionated heparin was
continued. Intravenous prostacyclin was administered. But
there was no clinical improvement. Therefore, a Computed
Tomographic Angiography (CTA) was done with the aim of
01
Citation: Arudchelvam J, Marasinghe A (2019) Accidental Intra-Arterial Injection of a Drug in a Patient with Radial Artery Variation; A Rarity Leading to a
Disaster. J Clinical Case Rep Case Stud 2019: 66-68.
SUPERFICIAL
PALMAR BRANCH
ULNAR
ARTERY
THROMBOSED
SUPERFICIAL
RADIAL ARTERY
Radial
artery
Figure 1: Computed Tomographic Angiography (CTA) showing site of
thrombosed Superficial Radial Artery (marked with multiple lines) beyond
the branching point (arrow) of Superficial Palmar Branch.
Figure 3: Image showing the hand with the site of the thrombosed Superficial
Radial Artery (interrupted black lines) and the site of cannulation (arrow).
an intervention. It confirmed that the abnormal artery was
thrombosed from the branching site of the superficial palmar
branch and the palmar arch was only partially visualised
[Figure 1]. A thrombectomy was done. Thrombi were
extracted but there was poor back bleeding after retrieval
of the clots. The artery was flushed with heparin. And the
arteriotomy was closed with 7/0 polypropylene interrupted
sutures. Following thrombectomy heparin infusion was
continued. Patient reported only moderate improvement of
the symptoms soon after the thrombectomy but gradually
the pain subsided. After one month of follow-up, the patient
J CliniJ Clinical Case Rep Case Stud 2019: 66-68.
developed gangrene of the tips of Thumb, index, middle and
little fingers [Figure 2]. She is awaiting fingertip amputation
with refashioning.
Discussion
The radial artery arises at the division of the brachial
artery about one centimetre below the elbow joint. It runs
along the radial side of the forearm. At the wrist, at the level
of the distal border of the Pronator Quadratus, it gives off
a superficial palmar branch (SPB). The superficial palmar
branch anastomoses with the ulnar artery to form the
superficial palmar arch. From the SPA, palmar metacarpal
arteries arise, which divides into proper digital arteries
to supply the fingers. Distal to the origin of the superficial
palmar branch, the radial artery continues (dorsal branch)
through the anatomical snuff box and enters the palm
through the first inter metacarpal space and anastomose
with the deep palmar branch of the ulnar artery to form the
deep palmar arch.
In some individuals the distal radial artery gives off
superficial palmar branch high in the forearm (as in our
patient). In this situation the continuation of the radial artery
(dorsal branch) deviates posteriorly and runs superficially
on the radial border of the forearm and then runs superficial
to the extensor pollicis longus tendon and then runs through
the first inter metacarpal space to enter the palmar space.
In this situation it can be accidentally cannulated as in our
patient. This variation occurs at a rate of 0.5% – 1% [3,4]. In
addition variations in the palmar arch anatomy occur and
some individuals do not have a proper palmar arch [5]. In
this incidence especially if there is a radial dominant digital
blood supply or if there is thrombosis of the palmar arch,
there will be finger ischemia as in our patient.
Intra-arterial injection of drugs results in thrombosis of
the artery by the following mechanisms [6,4]
• Occlusion of the vessels by particles in the drug
• Crystallization of the drug after injection
• Endothelial injury, chemical arteritis resulting in platelet
adhesions
• High osmolarity causing vessel injury [7]
Prevention of intra-arterial injection is the key in avoiding
such disasters and it includes the following aspects;
• Knowledge about the anatomical variations like the one
described in this case report
• Avoiding cannulation close the known neurovascular
bundle eg. cubital fossa
• Recognition of intra-arterial cannulation in case of
accidental insertion of a cannula. When the cannula is
within the vein the returning blood is of dark colour and
is not under pressure. If the cannula is within the artery
• There will be a pulsatile back bleeding of bright red blood
• There may be a hematoma formation and
02
Citation: Arudchelvam J, Marasinghe A (2019) Accidental Intra-Arterial Injection of a Drug in a Patient with Radial Artery Variation; A Rarity Leading to a
Disaster. J Clinical Case Rep Case Stud 2019: 66-68.

• If the cannula is connected with the infusion set or a References

syringe there will be back flow of blood into these under
high pressure.
If accidental intra-arterial cannulation is recognised the
cannula should be immediately removed and local pressure
should be applied to prevent hematoma formation. The
distal circulation should be monitored.
1. Mc Cormack LJ, Cauldwell EW, Anson, BJ (1953) Brachial and
antebrachial arterial patterns. Surg Gynecol Obstet 96: 43-54.
2. Uglietta JP, Kadir S (1989) Arteriographic study of variant arterial
anatomy of the upper extremities. Cardiovasc Inter Radiol 12: 145-148.
3. Beale EW, Behnam, A (2012) Injection injury of an aberrant superficial
radial artery requiring surgical intervention. J Hand Microsurg 4: 39-42.

In case of accidental intra-arterial injection, the same
cannula which was used for injection can be used to flush the
artery with heparin saline or for injection of thrombolytic
agents or injection of vasodilators [8] or it can also be used
to perform an angiography [4] and then removed.
Treatment options following intra-arterial
injection and thrombosis includes analgesics, systemic
heparinization, Catheter directed intra-arterial thrombolysis
(with streptokinase, urokinase) [9] and systemic use of
dextran and steroids [4]. Surgical interventions include
thrombectomy or bypass [6].
Prevention of accidental arterial cannulation by being
aware of the common sites of known neurovascular bundle
and to be aware of the variations like described in this case
is an essential step in reducing such disasters occurring in
the future
4. Sen S, Chini EN, Brown MJ (2005) Complications After Unintentional
Intra-arterial Injection of Drugs: Risks, Outcomes, and Management
Strategies. Mayo Clinic Proc 80: 783 - 795.
5. Ottone NE, Prum N, Dominguez M, Blasi E, Medan C, et al. (2010) Analysis
and Clinical Importance of Superficial Arterial Palmar Irrigation and its
Variants over 86 Cases. Int J Morphol 28: 157-164.
6. Rai KM, Rao KS, Maudar KK (1997) Accidental Intra-Arterial Drug
Injection A Case Report. Med J Armed Forces India 52: 137-139.
7. Evans JM, Latto IP, Ng WS (1974) Accidental intra-arterial injection of
drugs: a hazard of arterial cannulation: 3 case reports. Br J Anaesth 46:
463-466.
8. Silverman SH, Turner WW (1991) Intra-arterial drug abuse: new
treatment options. J Vasc Surg 14:111-114.
9. Corser G, Masey S, Jacob G, Kernoff P, Browne D (1985) Ischemia
following self-administered intra-arterial injection of methylphenidate
and diamorphine: a case report of treatment with intra-arterial
urokinase and review. Anaesthesia 40: 51-55.

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