Early Presentation of Acute Digital Ischemia After Intra-Arterial Injection Drug Use

A 37-year-old man with hypertension and asthma who injects fentanyl daily presented with rapidly progressive discoloration, swelling, and pain of the hand shortly after fentanyl injection into the radial artery and a reported crush injury. Despite preserved proximal arterial flow on computed tomography angiography and catheter-directed angiography, there was markedly sluggish perfusion in the digital arteries that did not respond to intra-arterial vasodilators. The patient was treated with topical nitroglycerin and supportive measures but subsequently developed dry gangrene of multiple digits requiring partial amputation. This case highlights an unusually early manifestation of microvascular ischemia despite patent major vessels, suggesting a multifactorial etiology involving vasospasm, chemical endothelial injury, distal embolic phenomena, and potential xylazine-associated toxicity. Early recognition and stepwise vascular assessment may support timely intervention while avoiding unnecessary escalation in similar presentations.