Bleomycin Electrosclerotherapy (BEST)

Background and indications

Infantile hemangiomas are the most common vascular tumors of childhood (4-5% of infants), characterized by a proliferative phase (0-12 months) followed by progressive involution (1-7 years). The vast majority involute spontaneously without treatment. Embolization is reserved for complicated hemangiomas resistant to propranolol medical treatment: hepatic hemangiomas with high-output heart failure, symptomatic adult hemangiomas (atypical location), or persistent residual hemangiomas.

In adults, aggressive vertebral hemangiomas (symptomatic with epidural extension) can also be treated by pre-operative embolization.

Pre-procedure assessment

Assessment includes MRI (characterization, extension, flow evaluation), Doppler ultrasound (vascular architecture), cardiac workup (if high-output heart failure suspected), and evaluation of response to medical treatment (propranolol as first-line for infantile hemangiomas).

Procedure

Under general anesthesia, a catheter is introduced through the femoral artery. Under fluoroscopic guidance, hemangioma feeding arteries are selectively catheterized. Embolization is performed with calibrated particles, acrylic glue, or coils depending on pedicle size and flow. For infantile hepatic hemangiomas, intra-arterial bleomycin or bevacizumab may be associated. The procedure takes 1 to 2 hours.

Results and scientific evidence

Embolization of infantile hepatic hemangiomas with propranolol-resistant heart failure offers flow control and hemodynamic improvement in 80-90% of cases. For aggressive vertebral hemangiomas, pre-operative embolization significantly reduces surgical bleeding. Propranolol remains first-line treatment for the vast majority of infantile hemangiomas (Léauté-Labrèze et al., New England Journal of Medicine, 2008; DOI: 10.1056/NEJMoa0708819).

Risks and complications

Non-target embolization (2-5%), skin necrosis (5-10% for superficial hemangiomas), local pain (20-30%). Specific risks vary by location.

Recovery

1-3 night hospitalization. Control MRI at 1-3 months.

Practical information

The procedure is performed as a short inpatient stay. It is performed by an interventional radiologist specialized in vascular malformations, in coordination with the pediatrician or surgeon.