Primary Management of Pediatric Arteriovenous Malformations by Combined Transarterial and Interstitial Bleomycin Sclerotherapy: A Technical Case Series
Dalia Koujah, Scott Willard, Carrie Schaefer, Sudhen Desai, Lavi Nissim, Martin Errea, Todd AbruzzoPurpose:
To assess the results of transarterial (TRA) and interstitial (IST) bleomycin sclerotherapy with or without bleomycin-loaded particle suspensions (BLP) for primary treatment of symptomatic arteriovenous malformations (AVM) in the pediatric population.
Materials and Methods:
A single-center, retrospective technical case series of pediatric patients undergoing primary AVM treatment by combined TRA (+/− BLP) plus IST is reported. BLP was prepared by mixing polyvinyl alcohol particles (Boston Scientific, Marlborough, MA) into solutions of bleomycin and Isovue 300 (Bracco, Monroe Township, NJ). Patient, procedural, and AVM data were obtained by chart review.
Results:
Between January 2017 and June 2025, 8 patients initiated primary AVM treatment by a combination of TRA plus IST, with (7) or without (1) BLP. Four early-stage and 4 late-stage AVM of the head and neck (N = 4) and extremities (N = 4) were treated in 17 sessions. The average procedural dose of bleomycin was 12.9 ± 3.0 mg. Patient age ranged from 6 to 18 years (12 ± 4.11). In 10 of 11, TRA performed with BLP; concurrent IST was administered. In 2 of 2, TRA performed without BLP; concurrent IST was administered. Three solo ISTs were performed. Follow-up ranged from 24 days to 26.5 months (13 ± 8.8 months). In BLP-treated patients, initial symptom remission was complete/near-complete in 4 and satisfactory in 3. Recurrent symptoms developed in 1 of 7 BLP-treated patients after 4–5 years. In the patient treated without BLP, satisfactory initial symptom remission was not achieved, and less than 25% AVM elimination was found on follow-up magnetic resonance imaging. In 5 of 5 BLP-treated patients with magnetic resonance imaging follow-up, >50% of AVM remained eliminated after 26 ± 8 weeks. Significant complications (Society of Interventional Radiology adverse event scale >2) were limited to 1 case of pulmonary hypersensitivity.
Conclusion:
Primary AVM treatment using a combination of TRA with BLP plus IST achieves a high rate of durable symptom remission with a low complication rate in well-selected pediatric patients.Level of Evidence: Level IV.