Background:

Arterial line placement has a major complication rate below 1%. Ischemic injury can occur in patients with impaired perfusion or hemodynamic instability. 
Reperfusion injury (RI) is a life-threatening situation and this is, to the best of our knowledge, the first report of its occurrence after radial artery cannulation (RAC).

Case Report:

68-year-old woman admitted to the ICU due to cardiogenic shock. Relevant treatment, including vasopressors, was started.
Arterial line was placed in left radial artery, but stopped working shortly after and was removed. Left forearm and hand became pale and cold. Doppler showed no flow in both ulnar and radial arteries, weak pulse in brachial artery. Vascular surgery team opts for conservative treatment.
After 12h left forearm pain as well as anesthesia and paresis of the I and II left fingers developed. Doppler showed permeable ulnar artery, no flow in radial artery from mid-forearm.
Restoration of circulation was attempted with peripheral nerve block (sympaticolysis), salicylate and arterial vasodilation (nimodipin), resulting in a better perfused hand, warm fingertips, but persistent ischemic area in the forearm.
Severe pain, worsening of the ischemic area and muscle rigidity in the entire left forearm and hand developed in the following 12h. Doppler showed no flow in both ulnar and radial arteries. Concomitantly, rapid deterioration of renal function was observed.
Mid-arm amputation was performed due to the presence of severe ischemia and RI.
The patient was released from the ICU on the 6th day.

Discussion:

Female sex, hypotension and use of vasopressors are known risk factors for development of hand ischemia after RAC.1
RI is a risk to be considered in the treatment of ischemia after RAC. Attempts to reperfuse the ischemic area after 4-6h can produce both local and systemic complications.2
In our case, the attempt to restore circulation after more than 12h led to both worsening of ischemia and RI with renal repercussion. 

References:

1.Chir Main. 2014 Sep;33(4):299-302
2.Cardiovasc Surg. 2002 Dec;10(6):620-30

Learning points:

This is a warning to those attempting restoration of circulation after ischemic complications due to RAC.
The golden period of 4-6h should be respected, as both worsening of ischemia and RI are a risk. Monitoring of renal function is essential, as remote RI can be complicated by the release of myoglobin from necrotizing muscle, and subsequent tubular injury.

04 / Reperfusion injury with renal repercussion leading to amputation as a complication of radial artery cannulation