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

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.

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.

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.