TAME is an emerging interventional technique for chronic musculoskeletal pain and vascular anomalies, with reported success in osteoarthritis and pain syndromes (2, 3). While previous studies have reported minimal complications, there is limited data on its safety in patients with vascular compromises. This case highlights the first documented severe complication following TAME with Imipenem/Cilastatin (IPM/CS), raising concerns about embolic agent selection and patient eligibility.

A 65-year-old male with a history of chronic venous ulcer presented with persistent leg pain and swelling. Clinical examination revealed an ulcerated lesion over the lower leg with surrounding skin hyperpigmentation and signs of chronic venous insufficiency. Computed tomography angiography identified a micro AVF in the right leg (Figure 1), confirmed by digital subtraction angiography (DSA) (Figure 2). Given his refractory pain and non-healing ulcer, he was referred for TAME as an alternative to surgical management.

Baseline laboratory investigations showed normal coagulation parameters and no active infection. Imaging confirmed a high-flow micro AVF supplying the ulcerated region. After multidisciplinary discussion, TAME was planned to use intra-arterial IPM/CS, based on prior studies supporting its efficacy in osteoarthritis and neovascularization (3).

A 4-French sheath was introduced via femoral artery access under ultrasound guidance. Superselective catheterization of the target feeding arteries was achieved using a microcatheter. A slow intra-arterial infusion of IPM/CS was performed, with a total of 1.5 ml of IPM/CS (500 mg in 5 ml contrast) administered into the anterior tibial artery under fluoroscopic guidance. Post-embolization angiography confirmed the occlusion of the abnormal microvasculature.

The patient was discharged without immediate complications. However, two days later, he returned with worsening lower limb swelling, erythema, and multiple fluid-filled blebs (Figure 3). These symptoms suggested acute tissue ischemia and an inflammatory response, raising concern for severe non-target embolization. The patients developed cellulitis and worsening tissue breakdown necessitated prolonged inpatient care, including intravenous antibiotics, wound debridement, and limb elevation. Over subsequent weeks, the patient gradually improved with conservative management, though ulcer healing was significantly delayed (Figure 4).

TAME has been extensively studied for osteoarthritis and chronic pain syndromes (1, 3), yet its use in patients with chronic venous ulcers and vascular compromise remains controversial. Liang et al. (4) reported the safety of IPM/CS infusion in treating hand osteoarthritis, noting only transient swelling and discoloration. Similarly, Kubo et al. (5) found high technical success with minimal complications in a cohort of 92 patients undergoing intra-arterial IPM/CS injection.

However, Lin et al. (6) highlighted potential risks, including arterial dissection and catheter-related complications. Our case presents a novel and severe complication, likely resulting from non-target embolization and impaired microvascular perfusion in an ulcerated limb. The inflammatory response following embolization may have exacerbated tissue hypoxia, leading to severe skin breakdown and prolonged recovery.

This case underscores the importance of careful patient selection, particularly for individuals with preexisting vascular insufficiency. The choice of embolic agent remains critical; while IPM/CS has demonstrated efficacy, its effects on compromised microcirculation warrant further investigation.

This case report highlights a rare but significant complication following TAME in a patient with chronic venous ulcer. While TAME remains a promising technique for chronic pain management, its application in patients with vascular compromise should be approached with caution. Future studies should focus on optimizing embolic agent selection and refining patient eligibility criteria to mitigate risks.