BACKGROUND. Consensus is lacking regarding optimal embolic agents for transarterial embolization (TAE) of renal angiomylipomas (AMLs). OBJECTIVE. To compare the safety and efficacy of TAE with polyvinyl alcohol (PVA), and of TAE with combination of lipiodol-bleomycin emulsion (LBE) and N-Butyl cyanoacrylate (NBCA)-lipiodol emulsion, for the treatment of patients with large or symptomatic AMLs. METHODS. This prospective study enrolled patients referred for TAE of a large (>4 cm) or symptomatic renal AML from July 2007 to December 2018. Patients were randomized to undergo TAE using PVA particles or combination of LBE and NBCA-lipiodol emulsion. Patients underwent serial clinical follow-up visits and follow-up CT or MRI examinations after TAE. Outcomes were compared between groups. RESULTS. Seventy-eight patients were enrolled. After exclusions, the analysis included 72 patients (15 male, 57 female; mean age, 35.0 years; 51 with hematuria, 66 with flank pain), 35 randomized to treatment by PVA and 37 randomized to treatment by combination of LBE and NBCA-lipiodol emulsion. Complete occlusion of all angiographically visible arterial supply was achieved in all patients. No major adverse event occurred in any patient. Mean follow-up after TAE was 77±45 months (range, 37-180 months). Frequency of resolution of hematuria after initial TAE without recurrence was greater after treatment by LBE and NBCA-lipiodol than by PVA (100.0% vs 80.0%, p=.03). At 12-month follow-up, frequency of complete resolution of flank pain was higher after treatment by LBE and NBCA-lipiodol emulsion than by PVA (100.0% vs 75.0%, p=.04). Mean reduction in AML volume at ≥36 months versus at baseline was greater in patients treated by LBE and NBCA-lipiodol than by PVA (98.0% vs 85.7%, p=.04). Frequency of complete response by mRECIST criteria at ≥36 months was greater in patients treated by LBE and NBCA-lipiodol than by PVA (94.6% vs 74.3%, p=.04). Rate of repeat TAE was higher among patients treated by PVA than by LBE and NBCA-lipiodol (25.7% vs 8.1%, p=.03). CONCLUSION. Superior outcomes after TAE of AML were achieved using LBE and NBCA-lipiodol than using PVA. CLINICAL IMPACT. TAE using combination of LBE and NBCA-lipiodol emulsion is a safe and effective treatment option for large or symptomatic AMLs.