Safety Profile of Sclerosing Agents in the Management of Low-Flow Vascular Malformations of the Head and Neck-A Systematic Review.

Abstract

Low-flow vascular malformations (LFVMs) of the head and neck, including venous and lymphatic malformations, represent a heterogeneous group of congenital anomalies frequently requiring intervention due to functional and esthetic impairment. Percutaneous sclerotherapy has emerged as a first-line treatment; however, no consensus exists regarding the optimal sclerosant, and all agents are associated with potential complications. This systematic review aims to evaluate and compare the safety profiles of commonly used sclerosing agents in the management of LFVMs of the head and neck. A systematic review was conducted according to PRISMA guidelines. PubMed, Scopus, and Google Scholar were searched for studies published between 2005 and 2025 reporting complications of sclerotherapy for LFVMs of the head and neck. Inclusion criteria comprised clinical studies with patients treated with intralesional sclerotherapy as a single modality and reporting treatment-related complications. Data extraction focused on type of malformation, sclerosant used, number of sessions, and complication rates per session. Complications were categorized as local or systemic and further stratified into minor and major events. A total of 64 studies encompassing 2508 patients and 5193 sclerotherapy sessions were included. The overall complication rate was 11.2% per session, with the majority being minor local events (8.8%). Bleomycin was the most frequently used agent (1516 sessions; 13.5% complication rate), predominantly associated with mild local and systemic inflammatory reactions. Ethanol (1072 sessions; 9%) demonstrated higher rates of major local complications (1.7%), including tissue necrosis and permanent nerve injury, as well as systemic effects such as hemoglobinuria and rare cardiopulmonary events. Sodium tetradecyl sulfate (STS) (1061 sessions; 9.5%) showed a moderate complication profile but carried risks of necrosis and airway edema. Polidocanol (860 sessions; 4.2%) and doxycycline (158 sessions; 3.8%) exhibited the most favorable safety profiles, with no major complications reported. Ethanolamine oleate had the highest complication rate (20.2%), including significant local adverse events. Sclerotherapy for LFVMs of the head and neck is generally safe, with most complications being minor and self-limiting. However, the safety profile varies significantly among sclerosants. Given the absence of standardized guidelines and comparative efficacy data, safety considerations should play a central role in sclerosant selection.