We report our experience with puncture, aspiration, injection, and reaspiration (PAIR) for the treatment of cystic echinococcosis in Bulgaria. PAIR was performed in 230 patients with 348 echinococcal cysts. At 12-month follow-up, 77.6% of the cysts, all cystic echinococcosis (CE) 1 and CE3a cysts according to the World Health Organization Informal Working Group classification, showed various degrees of obliteration. In 11.5% of cysts, all of which were > 10 cm-type CE1, a significant amount of fluid persisted, and they were punctured again. Of those, 16 (4.6%) contained protoscolices and were treated by a second PAIR. The remaining 24 (6.9%) cysts were treated by simple aspiration or drainage. No significant reduction in size and no changes in the structure were observed in 10.9% of cysts, all of which were classified as CE2 or CE3b. Complications developed in 25.2% of patients, including severe anaphylactic reaction in two (0.9%) patients. Our experience confirms that PAIR is a successful first-choice treatment when a stage-specific approach is taken.