The Efficacy of Bleomycin Sclerotherapy in the Treatment of Low-Flow Vascular Malformation

Duraid Mahmoud Jamil; Haider Fadel Salman; Zaid Hadi Hammoodi

doi:10.59675/U316

Authors

Duraid Mahmoud Jamil Diagnostic Radiology, The Scientific Council of the Iraqi Board of Medical Specializations, Baghdad, Iraq Author
Haider Fadel Salman Diagnostic Radiology, The Scientific Council of the Iraqi Board of Medical Specializations, Baghdad, Iraq Author
Zaid Hadi Hammoodi Ghazi Al-Hariri Hospital for Surgical Specialties, Baghdad, Iraq Author

DOI:

https://doi.org/10.59675/U316

Keywords:

Low-flow venous malformations, Bleomycin sclerotherapy, Vascular anomalies, Thrombotic response.

Abstract

Background: Low-flow venous malformations (VMs) are a class of vascular anomalies that are recognized by dilated or ectatic, thin-walled channels that are often involved with cosmetic sensitive areas or functionally crucial areas. Sclerotherapy has become the mainstay of treatment, and bleomycin is of great interest for its safety and efficacy.

Objective: To evaluate the clinical outcomes, safety, and thrombotic response associated with ultrasound-guided bleomycin foam sclerotherapy in patients with low-flow VMs.

Methods: In this prospective, single-center study, 23 patients (mean age 25.22 ± 17.30 years; 52.2% female) were treated at a triage practice in Baghdad. All patients received ultrasound-guided bleomycin foam injections intralesionally with a standardized maximum of 5 mg/session. The number of sessions (1-6 sessions), pre- treatment and post-treatment lesion sizes, and the development of a thrombotic reaction were recorded. Clinical outcomes were assessed using Doppler ultrasound and clinical examination at a four-month follow-up.

Results: Lesion location was predominantly on the face (43.5%), in addition to some involvement on the limbs and trunk. Most patients required one or two treatment sessions (Mean ± SD: 2.52 ± 1.50). Statistically significant decreases in dimensions were shown for the lesions (D1: decreased by 0.93 cm (p = 0.001) & D2 decreased by 0.66 cm (p = 0.001)). Complete thrombosis of their lesion occurred in 56.5% of cases, with partial regression in the rest. No significant complications occurred. The only minor adverse effects reported were transient erythema and local swelling (11.5%).

Conclusion: Bleomycin sclerotherapy safely and effectively treats low-flow VMs, producing significant volumetric reduction and thrombotic response with limited morbidity. This data support its wider use in mixed-anatomical presentations, particularly where aesthetic or functional outcomes are vital.

References

Budge EJ, Khalil Allam MA, Mechie I, Scully M, Agu O, Lim CS. Venous malformations: Coagulopathy control and treatment methods. Phlebology. 2021;36(5):361-74.

Colmenero I, Knöpfel N. Venous malformations in childhood: clinical, histopathological and genetics update. Dermatopathology. 2021;8(4):477-93.

Kim H, Joh J, Labropoulos N. Characteristics, clinical presentation, and treatment outcomes of venous malformation in the extremities. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2022;10(1):152-8.

Ahlawat S, Fayad LM, Durand DJ, Puttgen K, Tekes A. International society for the study of vascular anomalies classification of soft tissue vascular anomalies: survey-based assessment of musculoskeletal radiologists’ use in clinical practice. Current problems in diagnostic radiology. 2019;48(1):10-6.

Tawfik HA, Dutton JJ. Orbital vascular anomalies: a nomenclatorial, etiological, and nosologic conundrum. Ophthalmic Plastic & Reconstructive Surgery. 2022;38(2):108-21.

Putra J, Al-Ibraheemi A. Vascular anomalies of the head and neck: a pediatric overview. Head and Neck Pathology. 2021;15(1):59-70.

Zhou J, Zhao Z, Sun T, Liu W, Yu Z, Liu J, et al. Efficacy and safety of sirolimus for blue rubber bleb nevus syndrome: a prospective study. Official journal of the American College of Gastroenterology| ACG. 2021;116(5):1044-52.

Beijnen UE, Saldanha F, Ganske I, Upton J, Taghinia AH. Verrucous venous malformations of the hand. Journal of Hand Surgery (European Volume). 2019;44(8):850-5.

Borst AJ, Nakano TA, Blei F, Adams DM, Duis J. A primer on a comprehensive genetic approach to vascular anomalies. Frontiers in Pediatrics. 2020;8:579591.

Butnariu LI, Gorduza EV, Florea L, Țarcă E, Moisă ȘM, Trandafir LM, et al. The Genetic Architecture of Vascular anomalies: current data and future therapeutic perspectives correlated with Molecular mechanisms. International Journal of Molecular Sciences. 2022;23(20):12199.

Weitz-Tuoretmaa A. Low-Flow Vascular Malformations: Genetics and Quality of Life after Endovascular Sclerotherapy. 2022.

Schmidt VF, Cangir Ö, Meyer L, Goldann C, Hengst S, Brill R, et al. Outcome of bleomycin electrosclerotherapy of slow-flow malformations in adults and children. European Radiology. 2024;34(10):6425-34.

Tiwary SK. Investigations in Vascular Malformations. Vascular Malformations. 2021:105-25.

Gibson CR, Barnacle AM. Vascular anomalies: special considerations in children. CVIR endovascular. 2020;3(1):60.

Soulez G, Gilbert P, Giroux M-F, Racicot J-N, Dubois J. Interventional management of arteriovenous malformations. Techniques in Vascular and Interventional Radiology. 2019;22(4):100633.

Al-Antary ET, Gupte A, Carter J, Kaafarani M, Howard M, Edwards H, et al. Curing childhood cancer the “Natural” Way: Nature as the source of chemotherapy agents. Biochemical Pharmacology. 2023;213:115630.

Gembillo G, Ingrasciotta Y, Crisafulli S, Luxi N, Siligato R, Santoro D, et al. Kidney disease in diabetic patients: from pathophysiology to pharmacological aspects with a focus on therapeutic inertia. International journal of molecular sciences. 2021;22(9):4824.

Kang M, Connor DE, Parsi K. Treatment of venous malformations with tumescent-assisted sclero-embolic and ablative lasers (SEALs): safe and effective long-term outcomes. Phlebology. 2022;37(5):367-80.

Lin S-N, Wu Y-M, Siow T-Y, Yeh C-H, Toh C-H, Tseng T-Y, et al. Sclerotherapy with intralesional bleomycin injection under guidance of multi-slice CT for retrobulbar orbital low-flow vascular lesions—single-center experience. British Journal of Radiology. 2024;97(1153):186-94.

Brandão PS, Jacinto J, Rodrigues H, Bouça A, Mateus C, Reis J, et al. Intralesional bleomycin sclerotherapy for head and neck low-flow vascular malformations—A retrospective single-center experience. Journal of Cranio-Maxillofacial Surgery. 2025.

Yang Y, Sun M, Ma Q, Cheng X, Ao J, Tian L, et al. Bleomycin A5 sclerotherapy for cervicofacial lymphatic malformations. Journal of vascular surgery. 2011;53(1):150-5.

Redkar RG, Chigicherla S, Joshi S, Bangar A, Tewari S. Efficacy of intralesional bleomycin as an alternative approach in the management of vascular anomalies. Saudi Surgical Journal. 2017;5(2):60-4.

Nevesny F, Chevallier O, Falvo N, Guillen K, Malakhia A, Pellegrinelli J, et al. Bleomycin for percutaneous sclerotherapy of venous and lymphatic malformations: a retrospective study of safety, efficacy and mid-term outcomes in 26 patients. Journal of Clinical Medicine. 2021;10(6):1302.

Sainsbury DC, Kessell G, Fall AJ, Hampton FJ, Guhan A, Muir T. Intralesional bleomycin injection treatment for vascular birthmarks: a 5-year experience at a single United Kingdom unit. Plastic and reconstructive surgery. 2011;127(5):2031-44.

Spence J, Krings T, TerBrugge KG, Agid R. Percutaneous treatment of facial venous malformations: a matched comparison of alcohol and bleomycin sclerotherapy. Head & neck. 2011;33(1):125-30.

Agid N, Itsekzon Ze, Hendriks EJ, Terbrugge K, Agid R. Bleomycin sclerotherapy for venous vascular malformations of the tongue. Journal of NeuroInterventional Surgery. 2025.

De Maria L, De Sanctis P, Balakrishnan K, Tollefson M, Brinjikji W. Sclerotherapy for venous malformations of head and neck: systematic review and meta-analysis. Neurointervention. 2020;15(1):4-17.

Horbach S, Van De Ven J, Nieuwkerk P, Spuls PI, Van Der Horst C, Reekers J. Patient-reported outcomes of bleomycin sclerotherapy for low-flow vascular malformations and predictors of improvement. Cardiovascular and interventional radiology. 2018;41:1494-504.