Simply the (B)EST: what the interventionalist needs to know about (bleomycin) electrosclerotherapy for vascular anomalies.

Background: Vascular anomalies (VAs) require specialized multidisciplinary management. Bleomycin electrosclerotherapy (B)EST combines electroporation with intralesional bleomycin to enhance drug uptake while preserving surrounding tissue. Its role in treating VAs remains largely unexplored.

Objective: This systematic review evaluates the efficacy, safety, and procedural protocols of BEST in VA treatment.

Materials and methods: Following PRISMA guidelines, a systematic search was conducted in PubMed, Web of Science, and Scopus. Inclusion criteria included peer-reviewed studies on (B)EST for VAs, excluding reviews, editorials, and animal studies.

Results: Among 1237 records, 15 studies met the inclusion criteria, published between 2012 and 2025, primarily from Europe (13/15). A total of 566 patients were treated, including 445 with vascular malformations and 121 with vascular tumors (Kaposi sarcoma, angiosarcoma). (B)EST was mainly applied to slow-flow malformations. Across VA types, lesion-volume or symptom reduction rate was high, with five studies each reporting a 100% rate. Complete response in vascular tumors ranged from 65 to 100%. Most studies followed current guidelines, with bleomycin doses between 200 and 10,000 IU per session. Adverse effects were primarily local and self-limiting (Cardiovascular and Interventional Radiological Society of Europe classification CIRSE 1a-2); ulcerations occurred mainly in vascular tumors (CIRSE 3a); and skin hyperpigmentation (CIRSE 1a) was observed frequently, often partially resolving over time.

Conclusion: BEST shows promise for VA treatment, particularly venous and lymphatic malformations. While results suggest efficacy and safety, treatment heterogeneity and long-term outcomes require further investigation. Optimizing tailored protocols for each VA subtype and presentation is essential for defining (B)EST's role in VA management.

Key points: Question What is the role and efficacy of (bleomycin) electrosclerotherapy (B)EST in managing vascular anomalies resistant to conventional treatments, including tumors and malformations? Findings (B)EST demonstrated significant efficacy, achieving 65-100% complete responses in vascular tumors and 54.9-100% lesion or symptom reduction in vascular malformations. Clinical relevance (B)EST offers an option for patients with treatment-resistant or recurrent vascular anomalies, improving symptom-related outcomes. This is tempered by the absence of controlled trials, the need for cumulative dose pulmonary monitoring and the potential cosmetic burden of hyperpigmentation.