Electrosclerotherapy for Vascular Malformations:
The Game Changer

This innovative approach combines sclerotherapy with electrical stimulation to enhance the delivery and effectiveness of sclerosing agents. Specifically designed for vascular malformations, such as venous malformations and lymphatic malformations, electrosclerotherapy aims to provide a more targeted and efficient solution compared to traditional methods. 

Prof. Giacomo Colletti has pioneered and published a variant, called MEST, that optimizes parameters to make it more effective and maximize results

This the original paper on MEST for AVM: https://pubmed.ncbi.nlm.nih.gov/39855981/
The findings also apply on all other types of vascular malformations.

Understanding Vascular Malformations

What are Vascular Malformations and why they are not Angiomas

Vascular malformations are structural anomalies of blood vessels present at birth that arise from errors in vascular development, unlike angiomas (commonly called hemangiomas) which are true vascular tumors characterized by rapid endothelial cell proliferation after birth; in other words, angiomas grow by active cell division and often involute over time, while vascular malformations grow proportionally with the child and are composed of dysplastic but quiescent vessels that do not show the same proliferative phase. 

Because of these fundamental differences in biology and natural history, diagnosis, imaging, and management differ: vascular malformations are classified by the types of vessels involved (capillary, venous, lymphatic, arteriovenous or mixed) and often require specific therapies to control symptoms and prevent complications. New, less invasive techniques such as electrosclerotherapy can be particularly useful for sclerosing and remodeling abnormal channels in malformations, whereas angiomas are more likely to respond to systemic or topical anti-proliferative treatments.

What causes Vascular Malformations

When we grow from a foetus to a fully developed baby we need to build an immense number of new cells. This is true also for the cells that make up a vessel. Endothelial cells, which make the innermost layer of any vessel, are the most crucial ones. They regulate everything of that vessel: the shape, the thickness, how reacts to pressure and so on. We need to build billions of endothelial cells.
Now, every cell that replicates needs to read the entire DNA (point by point) and make two copies of it. Then it will distribute the two copies to the daughter cells, one DNA complex each.
Some parts of DNA are more difficult to read. A misreading of the content is more likely there.

In Vascular Malformations an endothelial cell makes a mistake in reading a single point in DNA (gene mutation). We now know the genes where these mutations occur. PIK3CA in Lymphatic Malformations, TEK/TIE2 in Venous Malformations, GNAQ in Capillary Malformations and MEK/MAP2K1 in AVM.

The ISSVA Classification

Issva is the International Society for the Study of Vascular Anomalies. It's the most relevant scientific society in the field of vascular anomalies. It created the first classification of vascular anomalies in 1996. Everyone dealing with vascular anomalies should stick to this. The classification is periodically reviewed. The last one is from 2025.

Understanding the ISSVA categories facilitates interdisciplinary communication, comparison of outcomes across studies, and development of evidence-based protocols.
Overall, adherence to the ISSVA Classification improves diagnostic accuracy and optimizes therapeutic decisions when electrosclerotherapy is being evaluated as part of a comprehensive vascular anomaly treatment plan.

Although the relevance of this may be rediscussed, vascular malformations can be further classified into Fast-Flow (arterio-venous malformations, AVM) and Slow-Flow. Technically capillary and venous malformations would both be considered slow-flow malformations. At the same time there is frequently no flow at all in lymphatic malformations. Thus, deciding that slow-flow vascular malformations are venous and lymphatic ones doesn't really make sense. However, this is what is conventionally accepted.

Types of Slow-Flow Malformations

Slow-flow vascular malformations encompass a range of conditions. These conditions present unique challenges in treatment and include:

• Venous malformations, characterized by abnormal clusters of veins, can cause pain, swelling, and disfigurement.
• Lymphatic malformations, involving the lymphatic system, may result in fluid-filled cysts or swelling in affected areas.

Both types fall under the category of slow-flow vascular malformations due to the slow, sluggish flow of blood or lymph within the malformed vessels.

Electrosclerotherapy offers a very effective approach that significantly improve outcomes for patients with vascular malformations of these slow-flow lesions.

Symptoms and Diagnosis

Symptoms of slow-flow vascular malformations can vary, and patients may experience a range of issues that depend on the type, size, and location of the lesion. These issues can include:

• Pain
• Swelling
• Skin discoloration
• Functional impairment

Diagnosis typically involves a thorough physical examination and often imaging studies such as MRI or ultrasound. Early and accurate diagnosis is essential for determining the most appropriate treatment strategy, which may include electrosclerotherapy, particularly when considering treatment of slow-flow vascular malformations or combined venous and lymphatic malformations.

Impact on Patients’ Lives

The impact of slow-flow vascular malformations on patients’ lives can be substantial, affecting physical, emotional, and social well-being. Chronic pain, swelling, and disfigurement can limit daily activities, impair self-esteem, and lead to social isolation. Treatment for slow-flow malformations aims to alleviate symptoms, improve function, and enhance quality of life. Electrosclerotherapy presents a minimally invasive option that holds promise for improving the outcomes and reducing the needed number of sessions for patients with vascular malformations. The success of electrosclerotherapy can be a game-changer for these patients, offering hope for a better future.

It is advisable that a physician with experience in EST performs the procedure for optimal results. The machine matters and so does the operator.

Treatment of Vascular Malformations

The treatment of vascular malformations has long been a complex challenge. Traditional approaches have included surgical resection, which can be invasive and may not always be feasible, as well as sclerotherapy using agents like intralesional bleomycin.
Usual approaches work well with most vascular malformations that are localized and not too big. More complex ones, like large, diffused or infiltrating ones, are not amenable to surgery and tend to respond poorly to bleomycin-based sclerotherapy.

Electrosclerotherapy offers a refined approach that can be both more effective and less invasive. Once again though, the results also depends on the operator's skills and experience.

Overview of Electrosclerotherapy

Electrosclerotherapy integrates sclerotherapy for low-flow vascular malformations with the application of electrical pulses. This combination leverages electroporation to create temporary pores in cell membranes, facilitating increased absorption of the injected sclerosant, such as bleomycin. The addition of electroporation to the injection of bleomycin makes this 100x more effective. By enhancing the delivery of bleomycin in the treatment, electrosclerotherapy aims to achieve more thorough obliteration of the abnormal vessels, thus improving outcomes for patients with vascular malformations. Our results show excellent response, also in difficult to manage cases.

Importance of Early Intervention

Early intervention is advisable in managing vascular malformations, especially head and neck vascular malformations, to prevent progression and minimize long-term complications. Identifying and treating slow-flow vascular malformations early can significantly improve a patient's quality of life. The study of vascular anomalies supports early intervention to prevent functional impairments and cosmetic disfigurement.
Electrosclerotherapy offers a minimally invasive option that can be considered as part of a comprehensive treatment plan for treating slow-flow vascular malformations, addressing symptomatic or diffused cases before they escalate.

Comparison with Traditional Treatments

When comparing electrosclerotherapy with traditional treatments, it is essential to consider the advantages it offers in terms of precision and efficacy.
Traditional sclerotherapy and surgical interventions may not always achieve complete resolution of vascular malformations, and they can carry risks such as scarring or recurrence.
Electrosclerotherapy, with bleomycin, offers a targeted approach that enhances the effect of the sclerosing agent.
This method reduces the number of treatments needed and improves the overall outcome as compared to bleomycin sclerotherapy alone, providing a superior treatment for slow-flow vascular malformations.

Use of Bleomycin in Electrosclerotherapy

Mechanism of Action

Bleomycin works by intercalating into DNA strands, causing strand breaks and inhibiting DNA synthesis, thus leading to cell death within the vascular malformation tissue.

But bleomycin is a bulk molecule that does not enter into cells easily.

Here is where lies the key of electrosclerotherapy: electroporation. The very brief electrical current is administered to create temporary pores (holes) in the cell's membrane, thus allowing bleomycin to enter in high amounts, augmenting its effects.

Benefits of Bleomycin Combination Therapy

There are several benefits to using a combination of bleomycin sclerotherapy and reversible electroporation in electrosclerotherapy for slow-flow vascular malformations. This approach allows for a lower bleomycin dose, reducing systemic toxicity while maintaining high efficacy. The combined effect of electroporation and bleomycin ensures that the drug is delivered directly to the affected cells within the venous malformation or lymphatic malformation. This precision is especially beneficial in head and neck vascular malformations, where minimizing damage to surrounding tissues is critical for patients with vascular malformations.

Safety and Efficacy Data

Clinical studies have demonstrated the safety and efficacy of bleomycin electrosclerotherapy in the treatment of vascular malformations. Research indicates that this treatment for slow-flow vascular malformations results in significant reductions in lesion size and symptom severity. The study of vascular anomalies shows that patients undergoing bleomycin electrosclerotherapy experience fewer complications compared to traditional surgical approaches, with minimal scarring and reduced risk of recurrence. Further data supports its use as a safe and effective option for treating slow-flow malformations.

Outcomes of Bleomycin Electrosclerotherapy

Success Rates in Treatment

The success rates associated with bleomycin electrosclerotherapy are impressive, with many patients experiencing significant improvement in their condition of venous and lymphatic malformation. Clinical trials have reported high rates of lesion reduction and symptom relief among patients with vascular malformations treated with this technique. These outcomes are particularly notable when compared to other treatment options for slow-flow vascular malformations, establishing electrosclerotherapy as a leading choice for those seeking effective solutions to treat their symptomatic slow-flow vascular malformations.

Long-Term Effects on Patients

The long-term effects of bleomycin electrosclerotherapy on patients with vascular malformations are generally positive, with many individuals experiencing sustained relief from symptoms and improved quality of life. Follow-up studies show that the reduction in lesion size achieved through electrosclerotherapy tends to be durable, with low rates of recurrence. Additionally, because electrosclerotherapy is a minimally invasive procedure, patients typically experience minimal scarring and a quick recovery, allowing them to return to their normal activities shortly after the treatment for slow-flow malformations.

Case Studies and Testimonials

Numerous case studies and testimonials highlight the transformative impact of modified electrosclerotherapy (MEST) on the lives of patients with vascular malformations. These stories often describe significant reductions in pain, swelling, and disfigurement, allowing individuals to regain confidence and participate more fully in daily life. Many patients express gratitude for the effectiveness of electrosclerotherapy, noting that it has provided them with relief that other treatments, such as intralesional bleomycin injection, were unable to achieve for these venous and lymphatic malformations. These personal accounts serve as a testament to the potential of electrosclerotherapy to improve outcomes for patients with vascular malformations.

MEST: Modified Electro-Sclero-Therapy. A Modification to maximize results

What is MEST - Modified Electro Sclero Therapy

Modified Electro-Sclero-Therapy (MEST) was conceived and published by Giacomo Colletti and represents an advanced refinement of electrosclerotherapy, designed to optimize outcomes in the treatment of vascular malformations. This enhanced technique builds upon the principles of electrosclerotherapy, incorporating specific modifications to maximize the delivery and effectiveness of sclerosing agents like intralesional bleomycin. By fine-tuning parameters such as electrical pulse duration, intensity, and frequency, MEST aims to achieve more precise targeting and obliteration of abnormal vessels, especially in complex cases of vascular malformations. The goal is to improve the outcome of bleomycin electrosclerotherapy.

What's the difference with conventional EST

The key difference between MEST and conventional electrosclerotherapy lies in the level of customization and optimization applied to the treatment protocol. While standard electrosclerotherapy follows a more generalized approach, MEST involves a tailored strategy based on the specific characteristics of each patient's vascular malformation. MEST may involve adjustments to the bleomycin dose, electrical stimulation parameters, and injection techniques to ensure optimal sclerosing agent distribution and cellular uptake. These modifications seek to enhance the precision and efficacy of the treatment, particularly for those with vascular malformations of the head or other sensitive areas, and to improve the outcome of bleomycin electrosclerotherapy. This tailored approach is also useful for head and neck vascular malformations.

Why ultrasound guidance is better than angiographic guidance

Ultrasound guidance offers several advantages over angiographic guidance in electrosclerotherapy for slow-flow vascular malformations. Specifically, ultrasound offers benefits such as:

• Real-time visualization of the targeted vessels and surrounding tissues, allowing for precise needle placement and accurate delivery of the sclerosing agent.
• Being non-invasive, as opposed to angiography.

Moreover, ultrasound can delineate the extent and morphology of the vascular malformation more clearly than angiography, aiding in treatment planning and monitoring.

Results of MEST

The results of MEST in treating vascular malformations have been excellent, with studies demonstrating significant improvements in lesion size, symptom relief, and overall patient satisfaction. Patients undergoing MEST often experience a marked reduction in pain, swelling, and disfigurement, leading to enhanced quality of life. In many cases, MEST can achieve complete or near-complete obliteration of the vascular malformation, preventing recurrence and minimizing the need for further interventions. These outcomes underscore the potential of MEST as a valuable tool in the management of slow-flow and high-flow vascular malformations, especially in patients who have not responded well to other therapies.

Patients' testimonials

Patients who have undergone MEST for slow-flow vascular malformations often share testimonials highlighting the transformative impact of the treatment on their lives, although this treatment is not available in the US. Many express gratitude for the significant reduction in pain and swelling, which has allowed them to resume normal activities and improve their overall well-being. Others praise the minimally invasive nature of MEST, noting that it has spared them the need for more extensive surgical procedures. These personal accounts serve as a powerful testament to the potential of MEST to improve outcomes for patients with vascular malformations.

FAQ on Modified Electrosclerotherapy

Is Modified Electrosclerotherapy (MEST) a safe procedure?

MEST is a medical procedure. As with other procedure it is not 100% risk free. However, if performed by a skilled and experienced physician, the risk of complications is very low.

What are the side effects of MEST Modified Electrosclerotherapy?

Most are linked to the use of Bleomycin. There is a 15-20% chance of having pigmentations if the post-surgical protocol is not meticulously followed. Any trauma to the skin, everywhere in the body, can cause these pigmentations. For this reason we recommend to avoid scratching and or doing anything that increases that risk for 10 days. In the medical literature there were reports of pulmonary fibrosis. This, however, was described when bleomycin was used in high doses and under continuous I.V. infusions. There aren't reports of pulmonary fibrosis when bleomycin is used as a sclerosant.
If the physician is not experienced enough, there is a risk of necrosis, i.e. tissue death. The risk is higher when treating AVMs.

How is the postoperative recovery of MEST modified electrosclerotherapy?

There is always swelling. The treated area and sometimes the surrounding tissues become very swollen. It can be very intense. This is not a complication, it's inherent in the process. There can be bruising. It is frequent. Small hematomas can also form. Those will subside spontaneously with time. In the early postoperative period there can be nerve weakness. This translates into reduced sensitivity or muscle weakness. This resolves spontaneously with time. Pain: this is usually moderate. However it can be sometimes pretty intense. It can take place days after the procedure and last a few weeks.

What do I have to do in the Postoperative period after MEST modified electrosclerotherapy?

Be careful not to put yourself at risk of skin trauma. Take a week off working. Rest. Take regular painkillers when needed. Go at the planned follow-up appointments. Contact your doctor if you see signs of tissue suffering, i.e. skin becoming very pale or bluish.

I have a Port Wine Stain (PWS) - Capillary Malformation: Am I a candidate for MEST modified electrosclerotherapy?

Yes, PWS, especially hypertrophic ones, respond to electrosclerotherapy with a decrease in tissue size and lightening of the overlying skin.

I have a Lymphatic Malformation (Lymphangioma): Am I a candidate for MEST modified electrosclerotherapy?

Yes, Lymphangiomas do respond to MEST. Macrocystic LMs respond well and fast. Microcystic or mixed Lymphatic malformations usually require more sessions.

I have a diffused complex Venous Malformation. Will MEST be effective?

Yes, modified electrosclerotherapy is very effective with venous malformations. No matter the size. It is beneficial in terms of size and pain. A complete resolution is often achievable but it may require more than one session.

I have a diffused complex AVM. Will MEST be effective?

Yes, MEST was actually conceived for complex, diffuse AVM. Results are excellent.

Future Directions in Electrosclerotherapy

The future of electrosclerotherapy holds exciting possibilities for further advancements and refinements in the treatment of vascular malformations. We are working on ongoing research efforts focused on optimizing the bleomycin dose and electrical stimulation parameters, exploring new sclerosing agents, and developing innovative delivery techniques to enhance the precision and effectiveness of electrosclerotherapy. Advances in imaging technologies, such as real-time ultrasound and MRI, promise to improve treatment planning and monitoring, enabling more targeted and personalized approaches. Ultimately, the goal is to continue pushing the boundaries of electrosclerotherapy to provide the best possible outcomes for patients with slow-flow vascular malformations or combined venous and lymphatic malformations, even though it is not available in the US.