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A 54-year-old man with a history of parenteral substance abuse, hepatitis C virus infection, and poor peripheral venous access presented to the emergency department with a history of progressive pain, swelling, and discoloration of his left thumb. Four days earlier, a friend had injected cocaine into the patient's left wrist. Examination revealed a swollen, dark thumb (Panel A) with tenderness over the thenar eminence, pain with motion, and an absence of capillary refill. An angiogram showed an abrupt interruption of flow in the radial artery at the wrist (Panel B, arrow), with no collateral flow to the thumb (Panel C). Exploratory surgery revealed a firm thrombus in the radial artery at the wrist and in the ulnar digital artery to the thumb; the entire distal vasculature appeared to be filled with thrombus, and attempts at surgical revascularization were unsuccessful. Despite subsequent heparin therapy, endogenous revascularization did not occur. Amputation of the thumb was required, but the rest of the hand was spared.
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