122 - Direct Puncture Sclerotherapy in Perineal Vascular Anomalies

Purpose: To describe the presentation, procedural techniques, and clinical response in patients with perineal vascular anomalies (VAs) treated with image-guided percutaneous sclerotherapy.

Materials and Methods: Five patients (age range 5-74; 3 females) with VAs in the perineal region treated with percutaneous sclerotherapy were included. Relevant comorbidities were present in select patients, including hidradenitis suppurativa, Klippel-Trenaunay syndrome, and PIK3CA mutation. All patients underwent preoperative ultrasound and pelvic MRI to confirm and characterize venous, lymphatic, or venolymphatic anomalies. Clinical presentation and response, time to reintervention, and complications were measured and analyzed. Medications used included intravascular 3% sodium tetradecyl sulfate (STS) foam and intravascular and intralesional bleomycin. STS was used for deeper and larger vascular channels while bleomycin was preferred for superficial or small channels at risk of rupture.

Results: Presenting symptoms included perineal pain (80%) and swelling (60%). Patients underwent a range of 1-9 and median of 4 interventions. The mean interval between sclerotherapy sessions was 42.4 weeks, with a median of 25.7 weeks (IQR 7.6-60.1 weeks). Three patients received STS alone constituted in a foam with air ranging from 1:1-4, one patient received bleomycin alone, and one patient received both. Treatments were well-tolerated without complication. Reintervention was primarily dictated by recurrence of symptoms in the setting of residual or recurrent vascular pockets that were eventually controlled. Patients treated with bleomycin had greater degree of symptom resolution, though there is insufficient power to assess for statistical significance.

Conclusion: Direct puncture sclerotherapy appears to be a safe and effective technique in the treatment of perineal and gluteal VAs. Because patients with VAs in the perineal region are often poor surgical candidates, sclerotherapy serves a critical role, offering durable clinical response, minimal recovery time, and improved quality of life. Further studies are warranted to define how STS and bleomycin concentrations and volumes influence lesion involution and long-term symptom relief.