Electrochemotherapy in the Management of Vascular Malformations: An Updated Systematic Review

Background: Vascular malformations (VMs) are congenital anomalies of the vascular system-capillary, venous, lymphatic, arteriovenous, or combined-frequently associated with notable morbidity and reduced quality of life. Electrochemotherapy (ECT), a locoregional treatment that combines chemotherapeutic agents (most commonly bleomycin) with electroporation, has emerged as a promising alternative in managing therapy-resistant or anatomically challenging lesions. Methods: A systematic review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, and the Cochrane Library were searched from inception to January 2025 for studies reporting on the efficacy and/or safety of ECT for vascular malformations. Data extraction encompassed study design, patient demographics, VM type, ECT protocols, outcomes, follow-up duration, and adverse events. Studies that lacked relevant outcome data or focused solely on other therapeutic approaches were excluded. Results: Twelve primary studies met the inclusion criteria and were analyzed. These covered diverse VMs, including venous, slow-flow, high-flow malformations, aggressive hemangiomas, and composite lesions in adult and pediatric populations. ECT protocols usually combined bleomycin (or occasionally other agents such as pingyangmycin or polidocanol foam) with various electroporation parameters. Across studies, ECT resulted in meaningful lesion-size reduction (50-97% in most cohorts), symptom relief (e.g., reduced pain and bleeding), and favorable cosmetic outcomes. While side effects (local edema, hyperpigmentation, procedure-related discomfort) were occasionally reported, they were typically mild and transient. Conclusions: ECT represents a valuable minimally invasive option in the therapeutic armamentarium for vascular malformations. Despite consistent demonstrations of efficacy and acceptable toxicity profiles, future high-quality, multicenter studies are warranted to confirm outcomes, refine treatment guidelines, and potentially expand its use as a standard of care.