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Premkumar M, Anand AC. Porto-sinusoidal Vascular Disease: Classification and Clinical Relevance. J Clin Exp Hepatol 2024; 14:101396. [PMID: 38601747 PMCID: PMC11001647 DOI: 10.1016/j.jceh.2024.101396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/05/2024] [Indexed: 04/12/2024] Open
Abstract
Non-cirrhotic portal hypertension (NCPH) is a well-recognized clinico-pathological entity, which is associated with clinical signs and symptoms, imaging, and endoscopic features of portal hypertension (PHT), in absence of cirrhosis. In patients with NCPH without known risk factors of PHT or extrahepatic portal vein thrombosis, the condition is called idiopathic non-cirrhotic portal hypertension (INCPH). There are multiple infectious, immune related causes, systemic diseases, drug and toxin exposures, haematological disorders, and metabolic risk factors that have been associated with this INCPH. However, the causal pathogenesis is still unclear. The Vascular liver disorders interest group group recently proposed porto-sinusoidal vascular disease (PSVD) as a syndromic entity, which provides definite histopathological criteria for diagnosis of NCPH (table 1). The three classical histo-morphological lesions specific for PSVD include obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal fibrosis. The PSVD definition includes patients with portal vein thrombosis, PVT, and even those without PHT, thus broadening the scope of diagnosis to include patients who may have presented early, prior to haemodynamic changes consistent with PHT. However, this new diagnosis has pros and cons. The cons include mandating invasive liver biopsy to assess the PSVD histological triad in all patients with NCPH, an erstwhile clinical diagnosis in Asian patients. In addition, the natural history of the subclinical forms of PSVD without PHT and linear progression to develop PHT is unknown yet. In this review, we discuss the diagnosis and treatment of INCPH/PSVD, fallacies and strengths of the old and new schema, pathobiology of this disease, and clinical correlates in an Asian context. Although formulation of standardised diagnostic criteria is useful for comparison of clinical cohorts with INCPH/PSVD, prospective clinical validation in global cohorts is necessary to avoid misclassification of vascular disorders of the liver.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anil C. Anand
- Department of Hepatology, Kalinga Institute of Medical Sciences, Bhubaneshwar, Odisha, India
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2
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Kelly C, Buscarini E, Manfredi G, Gregory S, Heneghan MA. Hepatic manifestations of hereditary haemorrhagic telangiectasia. Liver Int 2024; 44:2220-2234. [PMID: 38847503 DOI: 10.1111/liv.16008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/01/2024] [Accepted: 05/25/2024] [Indexed: 08/30/2024]
Abstract
Hereditary haemorrhagic telangiectasia is a genetic condition of abnormal blood vessel formation resulting from an imbalance of pro- and anti-angiogenic products of the transforming growth factor β/bone morphogenetic protein signalling pathway which contributes to vascular remodelling and maintenance. Hepatic vascular malformations are common although less frequently symptomatic, but may result in high-output cardiac failure, portal hypertension and biliary ischaemia. Whilst the understanding of the genetic and cell signalling pathways that are the hallmark of hereditary haemorrhagic telangiectasia have been clarified, there remain challenges in therapy for these patients. Only patients with symptomatic hepatic vascular malformations require treatment, with most (63%) responding to first-line medical therapy. For non-responders, bevacizumab is effective in reducing cardiac output in those with heart failure secondary to hepatic vascular malformations as well as other manifestations of the disease. Although liver transplantation is the only curative option, optimal timing is critical. Novel anti-angiogenetic drugs and those that target aberrant cell signalling pathway are being explored.
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Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, Kings College Hospital, London, UK
| | | | - Guido Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
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3
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Putra J, Kim GE. Diagnostic approach to hepatic vascular lesions: a paediatric perspective. Histopathology 2024. [PMID: 38924138 DOI: 10.1111/his.15250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 06/04/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Abstract
The pathological evaluation of hepatic vascular lesions in children requires special consideration. Inconsistent terminology, rarity of pathology specimens and overlapping pathological features between various lesions may pose a serious diagnostic challenge. In this review, we highlight the importance of using the International Society for the Study of Vascular Anomalies (ISSVA) classification scheme to characterise these lesions. Selected entities are discussed, including hepatic vascular tumours exclusively seen in the paediatric age group, hepatic infantile haemangioma and hepatic congenital haemangioma. Vascular malformations, with emphasis on their syndromic associations (venous malformation in blue rubber bleb naevus syndrome) and complications (hepatocellular nodules in Abernethy malformation) are also covered.
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Affiliation(s)
- Juan Putra
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
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4
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Omu R, Sato S, Nishimura A, Arii S, Ikeda Y, Uchida R, Nomura K, Sato S, Murata A, Shimada Y, Genda T. Retrograde Transcaval Obliteration for Refractory Hepatic Encephalopathy with Multiple Intrahepatic Portosystemic Venous Shunts. Intern Med 2024; 63:969-973. [PMID: 37587044 PMCID: PMC11045388 DOI: 10.2169/internalmedicine.2101-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/10/2023] [Indexed: 08/18/2023] Open
Abstract
An intrahepatic portosystemic venous shunt (IPSVS) is a rare vascular abnormality, particularly in patients without cirrhosis. An 80-year-old woman without a history of chronic liver disease was admitted to our hospital with hepatic encephalopathy. Computed tomography revealed multiple IPSVSs with two large shunts in segment 6. As conservative therapies were insufficient for treating the symptoms and reducing ammonia levels, retrograde transcaval obliteration was performed. The two large shunts were successfully embolized using detachable coils. Consequently, hyperammonemia and hepatic encephalopathy dramatically improved, and the triphasic wave patterns of the electroencephalogram disappeared. Retrograde transcaval obliteration may be effective for refractory hepatic encephalopathy with IPSVS.
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Affiliation(s)
- Rifa Omu
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Shunsuke Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Arisa Nishimura
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Shin Arii
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Yuji Ikeda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Ryota Uchida
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Kei Nomura
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Sho Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Ayato Murata
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Yuji Shimada
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Takuya Genda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
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Zarka J, Jeong K, Yabes JG, Ragni MV. Prevalence and risk factors for bleeding in hereditary hemorrhagic telangiectasia: a National Inpatient Sample study. Blood Adv 2023; 7:5843-5850. [PMID: 37567149 PMCID: PMC10561038 DOI: 10.1182/bloodadvances.2023010743] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 08/13/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a common bleeding disorder, but little is known regarding prevalence and risk factors for bleeding. Adult discharges with HHT and bleeding were identified by International Classification of Disease, 10th edition (ICD-10) codes in the National Inpatient Sample (NIS), 2016-2018. Prevalence estimates were weighted using NIS discharge-level weights to reflect national estimates. Risk factors for bleeding were determined by weighted multivariable logistic regression. Among 18 170 849 discharges, 2528 (0.01%) had HHT, of whom 648 (25.6%) had bleeding. Arteriovenous malformation (AVM) (31.9% vs 1.3%), angiodysplasia (23.5% vs 2.3%), telangiectasia (2.3% vs 0.2%), and epistaxis (17.9% vs 0.6%) were more common in HHT than in non-HHT patients (non-HHT), each P < .001. In contrast, menstrual (HMB) and postpartum bleeding (PPH) were less common in reproductive-age HHT than non-HHT, each P < .001. Anemia associated with iron deficiency (IDA), was equally common in HHT with or without bleeding (15.7% vs 16.0%), but more common than in non-HHT (7.5%), P < .001. Comorbidities, including gastroesophageal reflux (25.9% vs 20.0%) and cirrhosis (10.0% vs 3.6%) were greater in HHT than non-HHT, each P < .001. In multivariable logistic regression, peptic ulcer disease (OR, 8.86; P < .001), portal vein thrombosis (OR, 3.68; P = .006), and hepatitis C, (OR, 2.13; P = .017) were significantly associated with bleeding in HHT. In conclusion, AVM and angiodysplasia are more common and HMB and PPH less common in patients in those with HHT than non-HHT. IDA deficiency is as common in HHT with and without bleeding, suggesting ongoing blood loss and need for universal iron screening.
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Affiliation(s)
- Jabra Zarka
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kwonho Jeong
- University of Pittsburgh Center for Research on Health Care Data Center, Pittsburgh, PA
| | - Jonathan G. Yabes
- University of Pittsburgh Center for Research on Health Care Data Center, Pittsburgh, PA
| | - Margaret V. Ragni
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA
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6
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Matsuura H, Imajo K. Pale man with recurrent epistaxis. Emerg Med J 2023; 40:725-738. [PMID: 37758294 DOI: 10.1136/emermed-2022-212680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Hiroki Matsuura
- General Internal Medicine, Okayama City Hospital, Okayama, Japan
| | - Kenji Imajo
- Hematology, Okayama City Hospital, Okayama, Japan
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Çildağ MB, Gök M, Öztürk T, Köseoğlu ÖFK. Endovascular Treatment of a Giant Aneurysm of the Aberrant Right Hepatic Artery in a Patient with Osler-Weber-Rendu Syndrome: A Case Report. Vasc Specialist Int 2023; 39:25. [PMID: 37667663 PMCID: PMC10480046 DOI: 10.5758/vsi.230055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/24/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Osler-Weber-Rendu syndrome (OWR) is an autosomal dominant disorder characterized by recurrent epistaxis, mucocutaneous or visceral telangiectasias, and arteriovenous malformations in the lungs, liver, brain, and gastrointestinal tract. Hepatic artery aneurysms (HAAs) can also occur in OWR patients. HAAs are the second most common type of visceral artery aneurysm, and mortality rates are high owing to the lack of a tamponade effect. Anatomical variations of the celiacomesenteric vasculature are common, and the most common variation is that of the right hepatic artery originating from the superior mesenteric artery (SMA). We present the endovascular treatment of a patient with OWR and an aberrant right HAA originating from the SMA, with coil embolization and stent grafting. Giant HAAs can be treated endovascularly. However, stent graft placement should be reconsidered because of the need for antithrombotic medication, which may increase the incidence of epistaxis attacks in that patient group.
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Affiliation(s)
- Mehmet Burak Çildağ
- Department of Interventional Radiology, Adnan Menderes University Medicine Faculty, Aydın, Turkey
| | - Mustafa Gök
- Department of Interventional Radiology, Adnan Menderes University Medicine Faculty, Aydın, Turkey
| | - Tuğba Öztürk
- Department of Interventional Radiology, Adnan Menderes University Medicine Faculty, Aydın, Turkey
| | - Ömer Faruk Kutsi Köseoğlu
- Department of Interventional Radiology, Katip Çelebi University Training and Research Hospital, İzmir, Turkey
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Solela G, Adamseged M, Mohammed A. Hereditary hemorrhagic telangiectasia in a 42-year-old Ethiopian man presenting with severe anemia and high-output heart failure: A case report with literature review. Clin Case Rep 2023; 11:e7694. [PMID: 37448947 PMCID: PMC10337522 DOI: 10.1002/ccr3.7694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
Key Clinical Messages Hereditary hemorrhagic telangiectasia (HHT), a rare hereditary disorder, can cause recurrent massive epistaxis and gastrointestinal bleeding leading to severe anemia. Early diagnosis of HHT is essential to provide timely interventional therapies. Abstract HHT is a rare autosomal dominant hereditary disease that results in abnormal vasculogenesis in the skin, mucous membranes, and visceral organs such as the liver, lungs, and brain. Clinical diagnosis of HHT is made using the Curacao criteria, which include recurrent spontaneous nosebleeds, mucocutaneous telangiectasias, visceral organ involvement, and first-degree family history of HHT. Here, we report a patient with HHT from Ethiopia, who presented with recurrent epistaxis and gastrointestinal bleeding, and severe anemia requiring frequent blood transfusions as well as cauterization. The presented case is a 42-year-old Black Ethiopian man with frequent hospitalization for severe anemia and high-output heart failure requiring frequent blood transfusions. His mother had bilateral epistaxis since her early adulthood. Physical examination was significant for tachycardia, pale conjunctivae, and tiny erythematous lesions over his tongue, ejection systolic murmur and peripheral edema. Laboratory investigations revealed severe anemia with iron deficiency picture. Upper gastrointestinal endoscopy showed multiple telangiectasia spots and abdominal Doppler ultrasound showed hepatic arterio-venous malformations. He received supportive management and electrocauterization of nasal, gastric, and duodenal telangiectasias. To the best of our knowledge, this is the first case of HHT to be reported from Ethiopia. High degree of suspicion and early diagnosis of HHT is essential to start preventive screening and surveillance and provide timely interventional therapies. HHT can cause recurrent massive epistaxis and gastrointestinal bleeding leading to severe anemia and high-output heart failure. In resource limited settings, selective cauterization of telangiectasia will help to control bleeding, although it does not avoid recurrent bleeding.
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Affiliation(s)
- Gashaw Solela
- Department of Internal MedicineYekatit 12 Hospital Medical CollegeAddis AbabaEthiopia
| | - Michael Adamseged
- Department of Internal MedicineYekatit 12 Hospital Medical CollegeAddis AbabaEthiopia
| | - Abdulsemed Mohammed
- Division of Gastroenterology and Hepatology, Department of Internal MedicineCollege of Health Sciences, Addis Ababa UniversityAddis AbabaEthiopia
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9
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Ielasi L, Tonnini M, Piscaglia F, Serio I. Current guidelines for diagnosis and management of hepatic involvement in hereditary hemorrhagic teleangiectasia. World J Hepatol 2023; 15:675-687. [PMID: 37305373 PMCID: PMC10251273 DOI: 10.4254/wjh.v15.i5.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
Hereditary hemorrhagic teleangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is the most common cause of hepatic vascular malformations in adults. Different vascular shunts (arteriovenous, arterioportal or portovenous) lead to different clinical manifestations. Even though no hepatic-related symptoms are reported in the majority of cases, the severity of liver disease could lead to refractory medical conditions, in some cases requiring liver transplantation. The aim of this manuscript is to provide an updated overview of the current evidence regarding the diagnosis and treatment of HHT liver involvement and liver-related complications.
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Affiliation(s)
- Luca Ielasi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Department of Internal Medicine, Ospedale per gli Infermi di Faenza, Faenza 48018, Italy
| | - Matteo Tonnini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Ilaria Serio
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
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Natali GL, Cassanelli G, Paolantonio G, Parapatt GK, Gregori LM, Rollo M. Pediatric liver cirrhosis interventional procedures: from biopsy to transjugular intrahepatic portosystemic shunt. Pediatr Radiol 2023; 53:727-738. [PMID: 36121496 PMCID: PMC10027841 DOI: 10.1007/s00247-022-05492-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/15/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022]
Abstract
Cirrhosis is a complex diffuse process whereby the architecture of the liver is replaced by abnormal nodules because of the presence of fibrosis. Several pediatric diseases such as extrahepatic portal vein obstruction, biliary atresia, alpha-1-antitrypsin deficit and autoimmune hepatitis can lead to cirrhosis and portal hypertension in children. In this article the authors describe interventional radiology procedures that can facilitate the diagnosis and treatment of diseases associated with liver cirrhosis and portal hypertension in the pediatric population. These procedures include image-guided liver biopsy, mesenteric-intrahepatic left portal vein shunts, balloon-occluded retrograde transvenous obliteration, transjugular intrahepatic portosystemic shunts and splenic embolization.
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Affiliation(s)
- Gian Luigi Natali
- Interventional Radiology Unit in Oncohematology, Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio, 4, 00165, Rome, Italy.
| | - Giulia Cassanelli
- Interventional Radiology Unit in Oncohematology, Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio, 4, 00165, Rome, Italy
| | | | | | | | - Massimo Rollo
- Interventional Radiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Muacevic A, Adler JR, Sparacino GM. Pulmonary Arteriovenous Malformation in a Rare Case of Hereditary Hemorrhagic Telangiectasia. Cureus 2022; 14:e32365. [PMID: 36627987 PMCID: PMC9826734 DOI: 10.7759/cureus.32365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2022] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia is a rare condition presenting with anemia requiring transfusion and nosebleeds often refractory to supportive therapy. We discuss a case of a male in his 60s with a history of epistaxis, anemia requiring transfusions, and acute on chronic worsening shortness of breath presenting for evaluation. He was diagnosed with hereditary hemorrhagic telangiectasia. In addition, he was found to have pulmonary arteriovenous malformations and nonbleeding gastric telangiectasias. The patient underwent coil embolization of pulmonary arteriovenous malformations with a resolution of his shortness of breath and his anemia improved with iron supplementation.
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Wang QY, Feng YX, Zhu YW, Sun YX, Xu JD, Shi HM, Mao YM, Jiang HW. Case Report: Clinical characteristics and genetic analysis of two patients with hereditary hemorrhagic telangiectasia. Front Genet 2022; 13:954796. [PMID: 36092899 PMCID: PMC9452660 DOI: 10.3389/fgene.2022.954796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: To analyze the clinical features and genetic characteristics of two patients with hereditary hemorrhagic telangiectasia (HHT) and to review the relevant literature.Methods: The clinical data of two HHT patients admitted to the author’s hospital between April 2019 and February 2022 were retrospectively analyzed. Meanwhile, the genetic analysis was performed with their consent.Results: The first patient was a 62-year-old woman who had been complaining of shortness of breath and fever for 20 days. Her previous medical history included brain abscess drainage and video-assisted thoracoscopic surgery for a pulmonary hemangioma. A right heart catheterization revealed no pulmonary arterial hypertension, and an abdominal enhanced magnetic resonance imaging revealed multiple arteriovenous malformations in the liver. Her ACVRL1 heterozygous variants were discovered through whole-exon gene testing. The second case involved a 47-year-old woman who had been experiencing chest tightness for the past 2 years. Several years ago, she underwent brain abscess drainage and embolization of a pulmonary arteriovenous fistula. Ultrasound revealed generalized hepatic vascular dilation, and enhanced computed tomography revealed numerous pulmonary venous fistulas scattered in both lungs as well as multiple arteriovenous malformations in the liver. Her whole-exon gene testing revealed that she, like her son, had heterozygous ENG variants.Conclusion: HHT patients may experience infection, bleeding, dyspnea, and other symptoms. Imaging is important in disease diagnosis and management because early detection and treatment can prevent major complications and disability or even death.
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Affiliation(s)
- Qiu-Ying Wang
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yu-Xuan Feng
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Ying-Wei Zhu
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yu-Xia Sun
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Jing-Duan Xu
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Hui-Min Shi
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yi-Min Mao
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
- *Correspondence: Yi-Min Mao,
| | - Hong-Wei Jiang
- Department of Endocrinology, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
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Pria HD, Torres US, Faria SC, Velloni FG, Caiado AH, Tiferes DA, D'Ippolito G. Practical Guide for Radiological Diagnosis of Primary and Secondary Sclerosing Cholangitis. Semin Ultrasound CT MR 2022; 43:490-509. [DOI: 10.1053/j.sult.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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14
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Diffuse Cerebral Edema and Impending Herniation Complicating Hepatic Encephalopathy in Hereditary Hemorrhagic Telangiectasia. Case Rep Med 2022; 2022:2612544. [PMID: 35222647 PMCID: PMC8881178 DOI: 10.1155/2022/2612544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/28/2021] [Indexed: 11/19/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disease characterized by the formation of cutaneous and visceral telangiectasias and arteriovenous malformations (AVM). Multiple organs may be affected, including the nasal mucosa, skin, lungs, gastrointestinal tract, and brain. The following case highlights a unique manifestation of HHT in a patient with a gastrointestinal hemorrhage and epistaxis, resulting in hyperammonemia and diffuse cerebral edema and herniation. Clinicians should be aware of this potential complication in such patients and initiate ammonia-reducing agents early to avoid this devastating consequence.
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15
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Resolution of Precapillary Pulmonary Hypertension After Liver Transplantation for Hereditary Hemorrhagic Telangiectasia: Systematic Review and Case Report. Transplant Proc 2022; 54:135-143. [PMID: 34974893 DOI: 10.1016/j.transproceed.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/17/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a known complication of hereditary hemorrhagic telangiectasia (HHT) in patients with hepatic arteriovenous malformations (HAVM). Orthotopic liver transplantation (OLT) is a recognized treatment of HAVM in HHT, but its effect on PH has not been reported in detail before. METHODS Systematic review on HHT patients with pre- or postcapillary PH who underwent OLT and report of a case. RESULTS Twenty-one patients were included from 7 articles, all case reports or case series. All had high-output cardiac failure prior to OLT. Two patients had precapillary PH, both related to ALK1 mutations. All patients but 1 showed significant improvement or complete resolution of PH after transplantation. One patient died of acute cardiac failure postoperatively. We also report the case of a 72-year-old woman with type 3 HHT and severe mixed pre- and postcapillary PH. The patient presented with multiple HAVM, left-to-right shunting, and severe but partially reversible combined pre- and postcapillary PH, without ALK1 mutation. After recurrent cholangitis episodes, liver abscesses, and severe obstruction of the right-sided biliary tree, an interdisciplinary decision was taken to proceed with OLT despite PH. Intraoperatively, PH resolved almost instantly after hepatic artery ligation and hepatectomy. CONCLUSIONS In our patient, OLT completely abrogated mixed pre- and postcapillary PH. Based on this systematic review, we suggest that OLT should be considered a viable treatment option in patients with HHT, HAVM, and mixed pre- and postcapillary PH, featuring cardiac failure and drug responsive PH, rather than being seen as a major risk factor for cardiopulmonary complications.
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Sobrepera S, Monroe E, Gemmete JJ, Hallam D, Pinchot JW, Kaufman C. Imaging to intervention: a review of what the Interventionalist needs to Know about Hereditary Hemorrhagic Telangiectasia. CVIR Endovasc 2021; 4:84. [PMID: 34882285 PMCID: PMC8660943 DOI: 10.1186/s42155-021-00270-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/19/2021] [Indexed: 12/17/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a disorder that affects 1 in 5000-10,000 people worldwide and can result in devastating complications such as cerebral abscess, stroke, massive hemorrhage, and even death. HHT is an autosomal dominant disorder that leads to the formation of abnormal communication between the arteries and veins with a resultant spectrum of vascular anomalies. The disorder affects many organ systems and thus requires a dedicated multidisciplinary approach. Interventional radiologists are vital members of this team providing expertise not only in disease management, but in complex embolotherapy, helping to maintain the health of these patients. This article reviews clinical manifestations, screening guidelines, diagnostic criteria, and endovascular management of HHT.
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Affiliation(s)
- Stephanie Sobrepera
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Eric Monroe
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Danial Hallam
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Jason W Pinchot
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Claire Kaufman
- Department of Radiology & Imaging Sciences, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132-2140, USA.
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17
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Cusumano LR, Tesoriero JA, Wilsen CB, Sayre J, Quirk M, McWilliams JP. Predictors of heart failure symptoms in hereditary hemorrhagic telangiectasia patients with hepatic arteriovenous malformations. Orphanet J Rare Dis 2021; 16:478. [PMID: 34794458 PMCID: PMC8600745 DOI: 10.1186/s13023-021-02109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatic arteriovenous malformations (AVMs) in hereditary hemorrhagic telangiectasia (HHT) patients are most commonly hepatic artery to hepatic venous shunts which can result in high-output heart failure. This condition can be debilitating and is a leading cause of liver transplantation in HHT patients. However, it is not known what characteristics can discriminate between asymptomatic patients and those who will develop heart failure symptoms. RESULTS 176 patients with HHT were evaluated with computed tomography angiography (CTA) between April 2004 and February 2019 at our HHT Center of Excellence. 63/176 (35.8%) patients were found to have hepatic AVMs on CTA. 18 of these patients were excluded because of the presence of another condition which could confound evaluation of heart failure symptoms. In the remaining 45 patients included in our cohort, 25/45 (55.6%) patients were classified as asymptomatic and 20/45 (44.4%) were classified as symptomatic, and these groups were compared. In symptomatic patients, mean common hepatic artery (CHA) diameter was significantly higher (11.1 versus 8.4 mm) and mean hemoglobin levels were significantly lower (10.7 vs 12.6 g/dL). A stepwise multiple logistic regression analysis demonstrated that both CHA diameter and hemoglobin level were independent predictors of heart failure symptoms with ORs of 2.554 (95% CI 1.372-4.754) and 0.489 (95% CI 0.299-0.799), respectively. The receiver operator characteristic (ROC) curve of our analysis demonstrated an AUC of 0.906 (95% CI 0.816-0.996), sensitivity 80.0% (95% CI 55.7-93.4%), and specificity 75.0% (95% CI 52.9-89.4%). CONCLUSIONS CTA is an effective and easily reproducible method to evaluate hepatic involvement of HHT. Utilizing CTA, clinical, and laboratory data we determined CHA diameter and hemoglobin level were independent predictors of heart failure symptoms.
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Affiliation(s)
- Lucas R Cusumano
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Joseph A Tesoriero
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Craig B Wilsen
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - James Sayre
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Matthew Quirk
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Justin P McWilliams
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA.
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18
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Tessier S, Lipton BA, Ido F, Longo S, Nanda S. Pathogenesis and therapy of arteriovenous malformations: A case report and narrative review. Int J Crit Illn Inj Sci 2021; 11:167-176. [PMID: 34760664 PMCID: PMC8547675 DOI: 10.4103/ijciis.ijciis_127_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/24/2020] [Accepted: 01/05/2021] [Indexed: 12/03/2022] Open
Abstract
Arteriovenous malformations (AVMs) are abnormal communications between arteries and veins that lack intervening capillary beds. They have been described in almost every organ in the body, emerging sporadically or as part of well-described syndromes. Hereditary hemorrhagic telangiectasia (HHT) is a rare, progressive, and lifelong disease characterized by AVMs and recurrent hemorrhaging. In the last 2 decades, significant advances have been made in understanding the pathogenesis of this condition. The accumulation of knowledge has led to a natural evolution of therapy, from open surgery to endovascular procedures, and now to a role for medications in certain AVMs. Here, we review a case of HHT and describe the most up-to-date clinical practice, including diagnosis of HHT, subtypes of HHT, and medical therapy.
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Affiliation(s)
- Steven Tessier
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Brooke A Lipton
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Firas Ido
- Department of Pulmonary and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Sudip Nanda
- Department of Cardiology, St. Luke's University Health Network, Bethlehem, PA, USA
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19
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Barone M, Suppressa P, Viggiani MT, Lenato GM, Scardapane A, Chiumarulo L, Ambrosini N, Leo AD, Sabbà C. Minimal portosystemic encephalopathy: A new nosological entity in patients with hereditary haemorrhagic telangiectasia. Eur J Intern Med 2021; 90:43-48. [PMID: 34020869 DOI: 10.1016/j.ejim.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portosystemic shunts in Hereditary Haemorrhagic Telangiectasia (HHT) are often overlooked by conventional imaging although they could reduce hepatic clearance of gut-derived toxins. AIMS To evaluate, the presence of subclinical neurological alterations (SNAs), that we named "minimal portosystemic encephalopathy" (mPSE) in HHT patients without advanced liver disease (ALD). METHODS In this cross sectional study, consecutive HHT outpatients were firstly screened by critical flicker frequency (CFF) test (abnormal ≤39Hz), and the simplified animal naming test (S-ANT1) (abnormal <15) was used to confirm the diagnosis of mPSE. Furthermore, we evaluated the effect of lactulose administration on mPSE. Multi-slice CT, cerebral dynamic magnetic resonance, laboratory analyses and transient elastography were also used. RESULTS None of the 37 enrolled patients showed portosystemic shunts at imaging techniques. However, 33 patients had normal CFF values (CFF-) and 4 displayed CFF alterations (37.0±0.7Hz, CFF+). The S-ANT1 confirmed an impaired neurological performance (10.2±2.8) in CFF+ patients thus confirming the presence of mPSE. Noteworthy, lactulose administration determined a CFF increase (39.1±0.4Hz) and S-ANT1 normalization in these patients. Neither mPSE- nor mPSE+ patients had ALD and showed similar demographic, clinical and laboratory parameters. Finally, no mPSE+ patient showed radiologically-detectable brain vascular malformations or other brain abnormalities at imaging. CONCLUSIONS HHT patients represent a human model of mPSE secondary to portosystemic shunts escaping radiological detection. mPSE evaluation should be incorporated in HHT surveillance protocols since it can affect both health-related/social aspects and pharmacokinetics of orally administered drugs with a narrow therapeutic index and high hepatic first-pass uptake.
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Affiliation(s)
- Michele Barone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, (D.E.T.O.), University of Bari Aldo Moro, Policlinico University Hospital, Piazza G. Cesare 11, 70124 Bari, Italy.
| | - Patrizia Suppressa
- "Frugoni" Internal Medicine Unit, Centre for Rare Diseases, Interdepartmental Centre for Hereditary Haemorrhagic Telangiectasia, Interdisciplinary Department of Medicine (D.I.M.), VascERN HHT Reference Centre, University of Bari Aldo Moro, Policlinico University Hospital, Bari, Italy
| | - Maria Teresa Viggiani
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, (D.E.T.O.), University of Bari Aldo Moro, Policlinico University Hospital, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Gennaro Mariano Lenato
- "Frugoni" Internal Medicine Unit, Centre for Rare Diseases, Interdepartmental Centre for Hereditary Haemorrhagic Telangiectasia, Interdisciplinary Department of Medicine (D.I.M.), VascERN HHT Reference Centre, University of Bari Aldo Moro, Policlinico University Hospital, Bari, Italy
| | - Arnaldo Scardapane
- Interdisciplinary Department of Medicine-Radiology Unit, University of Bari Aldo Moro, Policlinico University Hospital, Bari, Italy
| | - Luigi Chiumarulo
- Neuroradiology Unit, Policlinico University Hospital, Bari, Italy
| | - Nicola Ambrosini
- "Frugoni" Internal Medicine Unit, Centre for Rare Diseases, Interdepartmental Centre for Hereditary Haemorrhagic Telangiectasia, Interdisciplinary Department of Medicine (D.I.M.), VascERN HHT Reference Centre, University of Bari Aldo Moro, Policlinico University Hospital, Bari, Italy
| | - Alfredo Di Leo
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, (D.E.T.O.), University of Bari Aldo Moro, Policlinico University Hospital, Piazza G. Cesare 11, 70124 Bari, Italy
| | - Carlo Sabbà
- "Frugoni" Internal Medicine Unit, Centre for Rare Diseases, Interdepartmental Centre for Hereditary Haemorrhagic Telangiectasia, Interdisciplinary Department of Medicine (D.I.M.), VascERN HHT Reference Centre, University of Bari Aldo Moro, Policlinico University Hospital, Bari, Italy
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20
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Farooqui M, Suriya S, Qeadan F, Vigil C, Wegele A, Ikram A, Quadri SA, Robinson M, Rodriguez-Lopez J, Ortega-Gutierrez S, Zafar A. Cerebrovascular and cardiovascular disease burden in patients with hereditary hemorrhagic telangiectasia. Neurol Sci 2021; 42:5117-5122. [PMID: 33779866 DOI: 10.1007/s10072-021-05135-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/20/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Hereditary hemorrhagic telangiectasia (HHT) is a rare genetic disease with prevalence of approximately 1 in 5000-10,000. We evaluated the prevalence and association of cerebrovascular and cardiovascular comorbidities in HHT patients using national database. METHODS Retrospective observational study was performed using National Inpatient Sampling (NIS) database for the year 2014. HHT patients and comorbidities were identified using ICD-9 codes. Univariate and multivariate analyses were performed using SAS. RESULTS Prevalence of HHT was 0.0119% with predominance in White population. Mean age of HHT patients was 59 years. Increased proportion of HHT patients had hypertension (46.8% vs 42%), anemia (28.9% vs 15.1%), chronic pulmonary disease (24.8% vs 16.4%), congestive heart failure (15.7% vs 7.5%), liver disease (7.9% vs 2.8%), migraine (4.5% vs 1.5%), and cerebrovascular malformations (0.8% vs 0.03%), whereas chronic kidney disease (12.7% vs 12.2%), headaches (1.3% vs 1.1%), seizures (0.7% vs 0.9%), transient ischemic attacks (1.06% vs 1.03%), ischemic (1.2% vs 1.0%), and hemorrhagic (0.5% vs 0.3%) strokes were similar to those without HHT. Multivariable model shows increase in cerebrovascular malformations (OR 11.04, CI 2.49-22.26, p < 0.0001), migraine (OR 3.23, CI 2.30-4.52, p < 0.0001), chronic blood loss anemia (OR 6.83, CI 5.36-8.71, p < 0.0001), congestive heart failure (OR 1.55, CI 1.26-1.91, p < 0.0001), chronic pulmonary disease (OR 1.30, CI 1.09-1.56, p = 0.0038), and hepatic disease (OR 2.63, CI 2.01-3.45, p < 0.0001) in HHT patients as compared to non-HHT patients. CONCLUSION There is a need for a large prospective registry of HHT patients that can corroborate these associations and burden of cerebrovascular and cardiovascular diseases.
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Affiliation(s)
- Mudassir Farooqui
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sajid Suriya
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Ashley Wegele
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Asad Ikram
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Syed A Quadri
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Myranda Robinson
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Atif Zafar
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
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21
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Hart BL, Mabray MC, Morrison L, Whitehead KJ, Kim H. Systemic and CNS manifestations of inherited cerebrovascular malformations. Clin Imaging 2021; 75:55-66. [PMID: 33493737 DOI: 10.1016/j.clinimag.2021.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 12/25/2022]
Abstract
Cerebrovascular malformations occur in both sporadic and inherited patterns. This paper reviews imaging and clinical features of cerebrovascular malformations with a genetic basis. Genetic diseases such as familial cerebral cavernous malformations and hereditary hemorrhagic telangiectasia often have manifestations in bone, skin, eyes, and visceral organs, which should be recognized. Genetic and molecular mechanisms underlying the inherited disorders are becoming better understood, and treatments are likely to follow. An interaction between the intestinal microbiome and formation of cerebral cavernous malformations has emerged, with possible treatment implications. Two-hit mechanisms are involved in these disorders, and additional triggering mechanisms are part of the development of malformations. Hereditary hemorrhagic telangiectasia encompasses a variety of vascular malformations, with widely varying risks, and a more recently recognized association with cortical malformations. Somatic mutations are implicated in the genesis of some sporadic malformations, which means that discoveries related to inherited disorders may aid treatment of sporadic cases. This paper summarizes the current state of knowledge of these conditions, salient features regarding mechanisms of development, and treatment prospects.
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Affiliation(s)
- Blaine L Hart
- Department of Radiology, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - Marc C Mabray
- Department of Radiology, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - Leslie Morrison
- Department of Neurology, MSC10 5620, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
| | - Kevin J Whitehead
- Division of Cardiovascular Medicine and the Program in Molecular Medicine, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA; George E. Wahlen Salt Lake City VA Medical Center, 500 Foothill Boulevard, Salt Lake City, UT 84148, USA.
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94143, USA.
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22
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Thompson KP, Nelson J, Kim H, Pawlikowska L, Marchuk DA, Lawton MT, Faughnan ME. Predictors of mortality in patients with hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2021; 16:12. [PMID: 33407668 PMCID: PMC7789194 DOI: 10.1186/s13023-020-01579-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/13/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Retrospective questionnaire and healthcare administrative data suggest reduced life expectancy in untreated hereditary hemorrhagic telangiectasia (HHT). Prospective data suggests similar mortality, to the general population, in Denmark's centre-treated HHT patients. However, clinical phenotypes vary widely in HHT, likely affecting mortality. We aimed to measure predictors of mortality among centre-treated HHT patients. HHT patients were recruited at 14 HHT centres of the Brain Vascular Malformation Consortium (BVMC) since 2010 and followed annually. Vital status, organ vascular malformations (VMs) and clinical symptoms data were collected at baseline and during follow-up (N = 1286). We tested whether organ VMs, HHT symptoms and HHT genes were associated with increased mortality using Cox regression analysis, adjusting for patient age, sex, and smoking status. RESULTS 59 deaths occurred over average follow-up time of 3.4 years (max 8.6 years). A history of anemia was associated with increased mortality (HR = 2.93, 95% CI 1.37-6.26, p = 0.006), as were gastro-intestinal (GI) bleeding (HR = 2.63, 95% CI 1.46-4.74, p = 0.001), and symptomatic liver VMs (HR = 2.10, 95% CI 1.15-3.84, p = 0.015). Brain VMs and pulmonary arteriovenous malformations (AVMs) were not associated with mortality (p > 0.05). Patients with SMAD4 mutation had significantly higher mortality (HR = 18.36, 95% CI 5.60-60.20, p < 0.001) compared to patients with ACVRL1 or ENG mutation, but this estimate is imprecise given the rarity of SMAD4 patients (n = 33, 4 deaths). CONCLUSIONS Chronic GI bleeding, anemia and symptomatic liver VMs are associated with increased mortality in HHT patients, independent of age, and in keeping with the limited treatment options for these aspects of HHT. Conversely, mortality does not appear to be associated with pulmonary AVMs or brain VMs, for which patients are routinely screened and treated preventatively at HHT Centres. This demonstrates the need for development of new therapies to treat chronic anemia, GI bleeding, and symptomatic liver VMs in order to reduce mortality among HHT patients.
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Affiliation(s)
- K P Thompson
- Toronto HHT Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B-1W8, USA
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - J Nelson
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA
| | - H Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA
- Institute for Human Genetics, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - L Pawlikowska
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA
- Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - D A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA
| | - M T Lawton
- Barrow Neurological Institute, Phoenix, AZ, USA
| | - Marie E Faughnan
- Toronto HHT Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B-1W8, USA.
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada.
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23
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Northup PG, Garcia-Pagan JC, Garcia-Tsao G, Intagliata NM, Superina RA, Roberts LN, Lisman T, Valla DC. Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:366-413. [PMID: 33219529 DOI: 10.1002/hep.31646] [Citation(s) in RCA: 274] [Impact Index Per Article: 91.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, CT.,Veterans Administration Healthcare System, West Haven, CT
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Riccardo A Superina
- Department of Transplant Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Surgical Research Laboratory, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Dominique C Valla
- Hepatology Service, Hospital Beaujon, Clichy, France.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
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24
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Olsen LB, Kjeldsen AD, Poulsen MK, Kjeldsen J, Fialla AD. High output cardiac failure in 3 patients with hereditary hemorrhagic telangiectasia and hepatic vascular malformations, evaluation of treatment. Orphanet J Rare Dis 2020; 15:334. [PMID: 33243256 PMCID: PMC7691053 DOI: 10.1186/s13023-020-01583-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This report addresses how patients with hereditary hemorrhagic telangiectasia (HHT) and high output cardiac failure (HOCF) due to hepatic vascular malformations, should be evaluated and could be treated. HHT is a genetic disorder, leading to vascular abnormalities with potentially serious clinical implications. In the liver, arteriovenous malformations occur in more than 70% of patients, but only about 8% present clinical symptoms such as HOCF with pulmonary hypertension and less commonly portal hypertension, biliary ischemia and hepatic encephalopathy. RESULTS Three female patients with HHT type 2 and HOCF caused by severe arteriovenous malformations in the liver are presented in this case series. The patients were seen at the HHT-Centre at Odense University Hospital. Treatment with either orthotopic liver transplantation (one patient) or bevacizumab (two patients) was initiated. All patients experienced marked symptom relief and objective improvement. New York Heart Association-class were improved, ascites, peripheral edema and hence diuretic treatment was markedly reduced or discontinued in all three patients. Bevacizumab also resulted in notable effects on epistaxis and anemia. CONCLUSION Our findings substantiate the importance of identification of symptomatic arteriovenous malformations in the liver in patients with HHT. Bevacizumab may possibly, as suggested in this case series and supported by previous case studies, postpone the time to orthotopic liver transplantation or even make it unnecessary. Bevacizumab represents a promising new treatment option, which should be investigated further in clinical trials.
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Affiliation(s)
- Lilian B Olsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark
| | - Anette D Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Otorhinolaryngology Head and Neck Surgery, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Mikael K Poulsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Jens Kjeldsen
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark.,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, Odense, Denmark
| | - Annette D Fialla
- HHT-Center Odense University Hospital, Part of VASCERN, Odense, Denmark. .,Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark. .,Institute of Clinical Research, Odense, Denmark.
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25
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Harwin J, Sugi MD, Hetts SW, Conrad MB, Ohliger MA. The Role of Liver Imaging in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2020; 9:jcm9113750. [PMID: 33233377 PMCID: PMC7700186 DOI: 10.3390/jcm9113750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 01/01/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder characterized by spontaneous epistaxis, telangiectasia, and visceral vascular malformations. Hepatic vascular malformations are common, though a minority are symptomatic. Symptoms are dependent on the severity and exact type of shunting caused by the hepatic malformation: Arteriosystemic shunting leads to manifestations of high output cardiac failure, and arterioportal shunting leads to portal hypertension. Radiologic imaging, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), is an important tool for assessing liver involvement. Doppler ultrasonography is the first-line screening modality for HHT-related liver disease, and it has a standardized scale. Imaging can determine whether shunting is principally to the hepatic vein or the portal vein, which can be a key determinant of patients’ symptoms. Liver-related complications can be detected, including manifestations of portal hypertension, focal liver masses as well as ischemic cholangiopathy. Ultrasound and MRI also have the ability to quantify blood flow through the liver, which in the future may be used to determine prognosis and direct antiangiogenic therapy.
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Affiliation(s)
- Joelle Harwin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
| | - Mark D. Sugi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Steven W. Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Miles B. Conrad
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Michael A. Ohliger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94143, USA; (J.H.); (M.D.S.); (S.W.H.); (M.B.C.)
- Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Correspondence:
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Ammonia Predicts Hepatic Involvement and Pulmonary Hypertension in Patients With Hereditary Hemorrhagic Telangiectasia. Clin Transl Gastroenterol 2020; 11:e00118. [PMID: 31977452 PMCID: PMC7056052 DOI: 10.14309/ctg.0000000000000118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION: Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is common and can be associated with severe clinical consequences, including portal hypertension, cardiac failure, and encephalopathy. However, there are no reliable clinical predictors of hepatic involvement and its associated complications, limiting appropriate identification of these patients. In this work, we define the utility of serum ammonia and liver biochemical tests (LFTs) in predicting hepatic HHT involvement and its complications. METHODS: We performed a retrospective study examining a well-characterized cohort of patients with HHT. Clinical characteristics, laboratory tests, liver imaging, transthoracic echocardiography assessment of right ventricular systolic pressure (RVSP), and history of other HHT-related outcomes were assessed. Patients were followed for the development of encephalopathy. RESULTS: Of 45 patients with definite HHT, 18 (40%) had elevated ammonia levels. An elevated ammonia associated with the presence of hepatic arteriovenous malformations (AVMs) on imaging (P < 0.03) and when combined with elevated liver tests increased the sensitivity for hepatic AVMs by 18% (55% for LFTs vs 73% for LFTs plus ammonia). Furthermore, an elevated serum ammonia in patients with HHT associated with an elevated RVSP (>35 mm Hg), providing an 80% sensitivity and 71% specificity for predicting the presence of pulmonary hypertension. In contrast, there was no association with an elevated serum ammonia and encephalopathy over a total of 859 months of follow-up. DISCUSSION: Elevated ammonia in a cohort of patients with HHT was associated with the presence of hepatic AVMs and elevated RVSP, but no other complications of HHT, including encephalopathy.
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Potential Second-Hits in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2020; 9:jcm9113571. [PMID: 33167572 PMCID: PMC7694477 DOI: 10.3390/jcm9113571] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disorder that presents with telangiectases in skin and mucosae, and arteriovenous malformations (AVMs) in internal organs such as lungs, liver, and brain. Mutations in ENG (endoglin), ACVRL1 (ALK1), and MADH4 (Smad4) genes account for over 95% of HHT. Localized telangiectases and AVMs are present in different organs, with frequencies which differ among affected individuals. By itself, HHT gene heterozygosity does not account for the focal nature and varying presentation of the vascular lesions leading to the hypothesis of a “second-hit” that triggers the lesions. Accumulating research has identified a variety of triggers that may synergize with HHT gene heterozygosity to generate the vascular lesions. Among the postulated second-hits are: mechanical trauma, light, inflammation, vascular injury, angiogenic stimuli, shear stress, modifier genes, and somatic mutations in the wildtype HHT gene allele. The aim of this review is to summarize these triggers, as well as the functional mechanisms involved.
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Kim AS, Henderson KJ, Pawar S, Kim MJ, Punjani S, Pollak JS, Fahey JT, Garcia‐Tsao G, Sugeng L, Young LH. Subaortic Membranes in Patients With Hereditary Hemorrhagic Telangiectasia and Liver Vascular Malformations. J Am Heart Assoc 2020; 9:e016197. [PMID: 33054561 PMCID: PMC7763373 DOI: 10.1161/jaha.120.016197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Patients with hereditary hemorrhagic telangiectasia have liver vascular malformations that can cause high‐output cardiac failure (HOCF). Known sequelae include pulmonary hypertension, tricuspid regurgitation, and atrial fibrillation. Methods and Results The objectives of this study were to describe the clinical, echocardiographic, and hemodynamic characteristics and prognosis of hereditary hemorrhagic telangiectasia patients with HOCF who were found to have a subaortic membrane (SAoM). A retrospective observational analysis comparing patients with and without SAoM was performed. Among a cohort of patients with HOCF, 9 were found to have a SAoM in the left ventricular outflow tract by echocardiography (all female, mean age 64.8±4.0 years). The SAoM was discrete and located in the left ventricular outflow tract 1.1±0.1 cm below the aortic annular plane. It caused turbulent flow, mild obstruction (peak velocity 2.8±0.2 m/s, peak gradient 32±4 mm Hg), and no more than mild aortic insufficiency. Patients with SAoM (n=9) had higher cardiac output (12.1±1.3 versus 9.3±0.7 L/min, P=0.04) and mean pulmonary artery pressures (36±3 versus 28±2 mm Hg, P=0.03) compared with those without SAoM (n=19) during right heart catheterization. Genetic analysis revealed activin receptor‐like kinase 1 mutations in each of the 8 patients with SAoM who had available test results. The presence of a SAoM was associated with a trend towards higher 5‐year mortality during follow‐up. Conclusions SAoM with mild obstruction occurs in patients with hereditary hemorrhagic telangiectasia and HOCF. SAoM was associated with features of more advanced HOCF and poor outcomes.
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Affiliation(s)
- Agnes S. Kim
- Department of Internal Medicine Calhoun Cardiology Center University of Connecticut School of Medicine Farmington CT
| | - Katharine J. Henderson
- Section of Vascular and Interventional Radiology Department of Radiology and Biomedical Imaging Yale University School of Medicine New Haven CT
| | - Sumeet Pawar
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Min Jung Kim
- Department of Internal Medicine Calhoun Cardiology Center University of Connecticut School of Medicine Farmington CT
| | - Shahnaz Punjani
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Jeffrey S. Pollak
- Section of Vascular and Interventional Radiology Department of Radiology and Biomedical Imaging Yale University School of Medicine New Haven CT
| | - John T. Fahey
- Section of Cardiology Department of Pediatrics Yale University School of Medicine New Haven CT
| | - Guadalupe Garcia‐Tsao
- Section of Digestive Disease Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Lissa Sugeng
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Lawrence H. Young
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
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Hereditary Hemorrhagic Telangiectasia and Refractory Ascites. ACG Case Rep J 2020; 7:e00458. [PMID: 33134402 PMCID: PMC7556362 DOI: 10.14309/crj.0000000000000458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/09/2020] [Indexed: 11/24/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia is a rare autosomal dominant disease that can involve the liver. The presence of arteriohepatic venous shunts can lead to high output cardiac failure and biliary ischemia, whereas arterioportal venous shunts can result in portal hypertension. Cirrhosis and nodular regenerative hyperplasia are also reported in these patients. Management of these patients in the setting of symptomatic liver disease is challenging. Transarterial embolization and hepatic artery ligation are usually considered palliative options. In selected cases, orthotopic liver transplantation can cure both liver disease and heart failure.
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Ota T, Kamiyama T, Kato T, Hanamoto T, Hirose K, Otsuka N, Matsuoka S, Taketomi A. A rare case of cavernous hemangioma accompanied with diffuse hepatic hemangiomatosis. Surg Case Rep 2020; 6:251. [PMID: 33001265 PMCID: PMC7530161 DOI: 10.1186/s40792-020-01023-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/21/2020] [Indexed: 01/18/2023] Open
Abstract
Background Hepatic cavernous hemangioma (CH) is the most common hepatic benign tumor. Most cases are solitary, asymptomatic, and found incidentally. In symptomatic cases with rapidly growing tumors and coagulopathy, surgical treatment is considered. In rare cases, diffuse hepatic hemangiomatosis (DHH) is reported as a comorbidity. The etiology of DHH is unknown. Case presentation A 29-year-old female patient had a history of endometriosis treated with oral contraceptives. Hepatic CH was incidentally detected in the segment IVa of the liver according to the Couinaud classification. Follow-up computed tomography (CT) and ultrasound sonography showed the growth of the lesion and formation of multiple new lesions near the first. Enhanced CT and magnetic resonance imaging (MRI) revealed that the new lesions were different from CH. Although oral contraceptives were stopped, all lesions grew in size. Malignancy and possibility of rupture of these tumors were considered due to the clinical course, and we opted for surgical removal of the tumors. Left liver lobectomy and cholecystectomy were performed. Surgical findings were small red spot spreading and a mass in segment IV of the liver. Pathological examination revealed a circumscribed sponge-like tumor with diffuse irregular extension to the adjacent area. Both of the lesions consisted of blood-filled dilated vascular spaces lined by flat endothelium without atypia. The diagnosis was hepatic CH with DHH. The patient was discharged on postoperative day 12 uneventfully. Conclusion We report the successful resection of CH with DHH. The case findings suggest a relationship between oral contraceptive use and enlargement of CH and DHH. Although DHH has been poorly understood, a few previously published cases reported DHH occurrence in patients using oral contraceptives. In such cases, the decision to perform surgical resection should be made after careful examination.
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Affiliation(s)
- Takuji Ota
- Surgery Department, Tomakomai General Hospital, 1-5-20 Shimizu-cho, Tomakomai, Hokkaido, Japan.
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido, Japan
| | - Takuya Kato
- Surgery Department, Tomakomai General Hospital, 1-5-20 Shimizu-cho, Tomakomai, Hokkaido, Japan
| | - Takayuki Hanamoto
- Surgery Department, Tomakomai General Hospital, 1-5-20 Shimizu-cho, Tomakomai, Hokkaido, Japan
| | - Kunihiro Hirose
- Surgery Department, Tomakomai General Hospital, 1-5-20 Shimizu-cho, Tomakomai, Hokkaido, Japan
| | - Noriyuki Otsuka
- Department of Pathology, Graduate School of Medicine/Faculty of Medicine, Hokkaido University, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido, Japan
| | - Shinichi Matsuoka
- Surgery Department, Tomakomai General Hospital, 1-5-20 Shimizu-cho, Tomakomai, Hokkaido, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido, Japan
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Goria O, Archambeaud I, Lemaitre C, Dutheil D, Plessier A, Rautou PE, Hernandez-Gea V, Valla D. Ischemic cholangiopathy: An update. Clin Res Hepatol Gastroenterol 2020; 44:486-490. [PMID: 32461060 DOI: 10.1016/j.clinre.2020.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Odile Goria
- Gastroenterology and hepatology unit, Charles Nicolle hospital, university hospital of Rouen, 1, rue de Germont, 76038 Rouen, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France.
| | - Isabelle Archambeaud
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Gastroenterology and hepatology unit, Nantes university hospital, Nantes, France
| | - Caroline Lemaitre
- Gastroenterology and hepatology unit, Charles Nicolle hospital, university hospital of Rouen, 1, rue de Germont, 76038 Rouen, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Danielle Dutheil
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Association of patients with vascular liver diseases (AMVF), department of hepatology, Beaujon hospital, 100, boulevard du Général-Leclerc, 92118 Clichy, France
| | - Aurélie Plessier
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of hepatology, Beaujon hospital AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Hamburg, Germany
| | - Pierre-Emmanuel Rautou
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of hepatology, Beaujon hospital AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Hamburg, Germany
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd). Health Care Provider of the European Reference Network onRare Liver Disorders (ERN-Liver), Spain
| | - Dominique Valla
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of hepatology, Beaujon hospital AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Hamburg, Germany
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Albitar HAH, Almodallal Y, Gallo De Moraes A, O'Brien E, Choby GW, Pruthi RK, Stokken JK, Kamath PS, Cajigas HR, DuBrock HM, Krowka MJ, Iyer VN. Intravenous Bevacizumab in Hereditary Hemorrhagic Telangiectasia-Related Bleeding and High-Output Cardiac Failure: Significant Inter-Individual Variability in the Need for Maintenance Therapy. Mayo Clin Proc 2020; 95:1604-1612. [PMID: 32753135 DOI: 10.1016/j.mayocp.2020.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 02/23/2020] [Accepted: 03/03/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To present our center's experience with a maintenance treatment algorithm for intravenous bevacizumab that allows for personalized therapy decisions. PATIENTS AND METHODS We reviewed all patients treated with intravenous bevacizumab for hereditary hemorrhagic telangiectasia-related bleeding and/or high-output cardiac failure (HOCF) from January 1, 2013, to July 1, 2019, at the Mayo Clinic, Rochester, Minnesota. Data regarding subsequent bevacizumab dosing were abstracted. RESULTS A total of 57 patients (n=40, 70.2% females) were identified with a median age of 65 (55 to 74; range, 37 to 89) years. High-cardiac output state was present in 21 patients (36.8%) and 10 (17.5%) were treated with intravenous bevacizumab primarily for HOCF. The median duration of follow-up after completion of the initial intravenous bevacizumab treatment was 25 (12.3 to 40.8; range, 0.1 to 65.4) months. A total of 20 (35.1%) patients with a median follow-up of 13.5 (range, 0 to 48.4) months required no maintenance dosing throughout the duration of follow-up. Among those who required subsequent maintenance doses, only a small fraction (8 patients; 14.0%) required regular maintenance doses every 4 to 8 weeks during follow-up whereas the majority of patients required intermittent "as-needed" doses at varying intervals. CONCLUSION There is significant inter-individual variability in the need for maintenance intravenous bevacizumab when patients are followed using a predefined bevacizumab maintenance dosing treatment algorithm. The use of "as-needed" maintenance bevacizumab appears to be an effective strategy for management of hereditary hemorrhagic telangiectasia-related bleeding and HOCF.
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Affiliation(s)
| | - Yahya Almodallal
- Division of Pediatric Allergy and Immunology, Mayo Clinic, Rochester, MN
| | | | - Erin O'Brien
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Hector R Cajigas
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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33
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Chen H, Wang S, Zhou J. Hereditary Hemorrhagic Telangiectasia With Pulmonary Hypertension and Hepatic Vascular Malformations. Am J Med Sci 2020; 360:322-323. [PMID: 32418611 DOI: 10.1016/j.amjms.2020.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/21/2019] [Accepted: 04/23/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Hui Chen
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China.
| | - ShengYu Wang
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Jing Zhou
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
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Ejiri K, Akagi S, Nakamura K, Amioka N, Ichikawa K, Yagi T, Ito H. Liver transplantation in a patient with hereditary haemorrhagic telangiectasia and pulmonary hypertension. Pulm Circ 2020; 9:2045894019896677. [PMID: 31903186 PMCID: PMC6923528 DOI: 10.1177/2045894019896677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/03/2019] [Indexed: 11/17/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia or Rendu-Osler-Weber syndrome is a
systemic vascular disease with autosomal dominant inheritance, mucocutaneous
telangiectasia, and repeated nasal bleeding due to vascular abnormalities.
Hereditary haemorrhagic telangiectasia may occasionally lead to complications,
including arteriovenous malformations and pulmonary hypertension. We present a
case of a 52-year-old female patient with hereditary haemorrhagic telangiectasia
who was referred to our hospital for treatment of pulmonary hypertension. She
had been diagnosed with hereditary haemorrhagic telangiectasia during
adolescence and was being followed up. Six months prior to presentation, she had
undergone coil embolization for pulmonary haemorrhage due to pulmonary
arteriovenous malformations. She was in World Health Organization functional
class IV, with a mean of pulmonary arterial pressure of 38 mmHg, a pulmonary
capillary wedge pressure of 10 mmHg, and a right atrial pressure of 22 mmHg. A
contrast-enhanced computed tomography angiography showed large arteriovenous
malformations in the liver. Right heart catheterization revealed an increase in
oxygen saturation in the inferior vena cava between the supra- and infra-hepatic
veins, low pulmonary vascular resistance, and high right atrial pressure. Hence,
she was diagnosed with hereditary haemorrhagic telangiectasia with pulmonary
hypertension due to major arteriovenous shunt resulting from arteriovenous
malformations in the liver. Therefore, we considered liver transplantation as an
essential treatment option. She underwent cadaveric liver transplantation after
a year resulting in dramatic haemodynamic improvement to World Health
Organization functional class I. Liver transplantation is a promising treatment
in patients with hereditary haemorrhagic telangiectasia and pulmonary
hypertension resulting from arteriovenous shunt caused by arteriovenous
malformations in the liver.
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Affiliation(s)
- Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama City, Japan
| | - Satoshi Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama City, Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama City, Japan
| | - Naofumi Amioka
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama City, Japan
| | - Keishi Ichikawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama City, Japan
| | - Takahito Yagi
- Department of Hepato-Biliary-Pancreatic Surgery, Okayama University Hospital, Okayama City, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama City, Japan
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Abstract
Disorders of the mesenteric, portal, and hepatic veins and mesenteric and hepatic arteries have important clinical consequences and may lead to acute liver failure, chronic liver disease, noncirrhotic portal hypertension, cirrhosis, and hepatocellular carcinoma. Although literature in the field of vascular liver disorders is scant, these disorders are common in clinical practice, and general practitioners, gastroenterologists, and hepatologists may benefit from expert guidance and recommendations for management of these conditions. These guidelines represent the official practice recommendations of the American College of Gastroenterology. Key concept statements based on author expert opinion and review of literature and specific recommendations based on PICO/GRADE analysis have been developed to aid in the management of vascular liver disorders. These recommendations and guidelines should be tailored to individual patients and circumstances in routine clinical practice.
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Al-Samkari H, Albitar HA, Olitsky SE, Clancy MS, Iyer VN. Systemic bevacizumab for high-output cardiac failure in hereditary hemorrhagic telangiectasia: an international survey of HHT centers. Orphanet J Rare Dis 2019; 14:256. [PMID: 31727111 PMCID: PMC6857247 DOI: 10.1186/s13023-019-1239-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/22/2019] [Indexed: 11/20/2022] Open
Abstract
Background Systemic bevacizumab is a novel targeted anti-angiogenic therapy for high-output cardiac failure (HOCF) in hereditary hemorrhagic telangiectasia (HHT) but published data is limited. This survey-based study measured physician-reported safety, effectiveness and current treatment practices for systemic bevacizumab in HHT-HOCF. Methods A 27-item survey was sent to center directors of 31 international HHT Centers of Excellence. Results Response rate was 74% with centers reporting 150 total patients receiving systemic bevacizumab for HHT-HOCF. Approximately two-thirds of centers had treated ≥5 patients. All centers utilize a 5 mg/kg dose for induction treatment and most administer 6 doses (range, 4–6) every 2 weeks, although maintenance regimens varied considerably. Center directors reported bevacizumab to be effective, with 55% reporting significant improvement in cardiac index and HOCF symptoms in most patients treated with bevacizumab, although normalization of cardiac parameters was uncommon. Adverse events were uncommon with three-quarters of centers reporting adverse event rates < 10%. Discontinuation for adverse events or ineffectiveness was rare. Bevacizumab was typically administered by hematologists and pulmonologists (50 and 39% of centers, respectively), with highly variable thresholds for initiation. Although half the centers reported difficulty with the insurance approval process, 70% of centers were ultimately able to obtain coverage for most or all of their patients. Conclusions Systemic bevacizumab is a widely-used therapy for HHT-HOCF with reasonable safety and effectiveness. HHT centers appear to vary considerably in maintenance treatment practices and disease severity thresholds for initiation of bevacizumab in HHT-related HOCF.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place Suite 118 Office 112, Boston, MA, 02114, USA.
| | - Hasan A Albitar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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Desroches-Castan A, Tillet E, Ricard N, Ouarné M, Mallet C, Belmudes L, Couté Y, Boillot O, Scoazec JY, Bailly S, Feige JJ. Bone Morphogenetic Protein 9 Is a Paracrine Factor Controlling Liver Sinusoidal Endothelial Cell Fenestration and Protecting Against Hepatic Fibrosis. Hepatology 2019; 70:1392-1408. [PMID: 30964206 DOI: 10.1002/hep.30655] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/04/2019] [Indexed: 12/15/2022]
Abstract
Bone morphogenetic protein 9 (BMP9) is a circulating factor produced by hepatic stellate cells that plays a critical role in vascular quiescence through its endothelial receptor activin receptor-like kinase 1 (ALK1). Mutations in the gene encoding ALK1 cause hereditary hemorrhagic telangiectasia type 2, a rare genetic disease presenting hepatic vessel malformations. Variations of both the circulating levels and the hepatic mRNA levels of BMP9 have been recently associated with various forms of hepatic fibrosis. However, the molecular mechanism that links BMP9 with liver diseases is still unknown. Here, we report that Bmp9 gene deletion in 129/Ola mice triggers hepatic perisinusoidal fibrosis that was detectable from 15 weeks of age. An inflammatory response appeared within the same time frame as fibrosis, whereas sinusoidal vessel dilation developed later on. Proteomic and mRNA analyses of primary liver sinusoidal endothelial cells (LSECs) both revealed that the expression of the LSEC-specifying transcription factor GATA-binding protein 4 was strongly reduced in Bmp9 gene knockout (Bmp9-KO) mice as compared with wild-type mice. LSECs from Bmp9-KO mice also lost the expression of several terminal differentiation markers (Lyve1, Stab1, Stab2, Ehd3, Cd209b, eNos, Maf, Plvap). They gained CD34 expression and deposited a basal lamina, indicating that they were capillarized. Another main characteristic of differentiated LSECs is the presence of permeable fenestrae. LSECs from Bmp9-KO mice had a significantly reduced number of fenestrae. This was already observable in 2-week-old pups. Moreover, we could show that addition of BMP9 to primary cultures of LSECs prevented the loss of their fenestrae and maintained the expression levels of Gata4 and Plvap. Conclusion: Taken together, our observations show that BMP9 is a key paracrine regulator of liver homeostasis, controlling LSEC fenestration and protecting against perivascular hepatic fibrosis.
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Affiliation(s)
| | - Emmanuelle Tillet
- BCI Laboratory, Université Grenoble Alpes, Inserm, CEA, Grenoble, France
| | - Nicolas Ricard
- BCI Laboratory, Université Grenoble Alpes, Inserm, CEA, Grenoble, France
| | - Marie Ouarné
- BCI Laboratory, Université Grenoble Alpes, Inserm, CEA, Grenoble, France
| | - Christine Mallet
- BCI Laboratory, Université Grenoble Alpes, Inserm, CEA, Grenoble, France
| | - Lucid Belmudes
- BGE Laboratory, Université Grenoble Alpes, CEA, Inserm, Grenoble, France
| | - Yohann Couté
- BGE Laboratory, Université Grenoble Alpes, CEA, Inserm, Grenoble, France
| | - Olivier Boillot
- Liver Transplant Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Jean-Yves Scoazec
- Department of Pathology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Sabine Bailly
- BCI Laboratory, Université Grenoble Alpes, Inserm, CEA, Grenoble, France
| | - Jean-Jacques Feige
- BCI Laboratory, Université Grenoble Alpes, Inserm, CEA, Grenoble, France
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Izgi E, Guven F, Ogul H. Multiple Pulmonary and Hepatic Arteriovenous Malformations in a Patient With Rendu-Osler-Weber Disease. Arch Bronconeumol 2019; 55:378. [DOI: 10.1016/j.arbres.2018.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/26/2018] [Accepted: 10/31/2018] [Indexed: 10/27/2022]
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Liver Transplantation Trends and Outcomes for Hereditary Hemorrhagic Telangiectasia in the United States. Transplantation 2019; 103:1418-1424. [DOI: 10.1097/tp.0000000000002491] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Salibe-Filho W, Piloto BM, Oliveira EPD, Castro MA, Affonso BB, Motta-Leal-Filho JMD, Bortolini E, Terra-Filho M. Pulmonary arteriovenous malformations: diagnostic and treatment characteristics. ACTA ACUST UNITED AC 2019; 45:e20180137. [PMID: 31241656 PMCID: PMC6733713 DOI: 10.1590/1806-3713/e20180137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/29/2018] [Indexed: 02/04/2023]
Abstract
Objective: To present a case series of pulmonary arteriovenous malformations (PAVMs), describing the main clinical findings, the number/location of pulmonary vascular abnormalities, the clinical complications, and the treatment administered. Methods: This was a retrospective observational study evaluating patients with PAVM divided into two groups: hereditary hemorrhagic telangiectasia (HHT); and idiopathic PAVM (iPAVM). Results: A total of 41 patients were selected for inclusion, but only 33 had PAVMs. After clinical evaluation, 27 and 6 were diagnosed with HHT and iPAVM, respectively. In the HHT group, the mean age was 49.6 years and 88.9% were female. In that group, 4 patients had an SpO2 of < 90% and the most common clinical finding was epistaxis. In the iPAVM group, the mean age was 48.1 years and 83.3% were female. In that group, 3 patients had an SpO2 of < 90%. Computed tomographic pulmonary angiography showed that most of the PAVMs were in the lower lobes: 56.4% in the HHT group and 85.7% in the iPAVM group. Embolization was performed in 23 patients (in both groups). At this writing, 10 patients are scheduled to undergo the procedure. One of the patients who underwent embolization was subsequently referred for pulmonary resection. Conclusions: In both of the PAVM groups, there was a predominance of women and of fistulas located in the lower lobes. Few of the patients had respiratory symptoms, and most had an SpO2 > 90%. The treatment chosen for all patients was percutaneous transcatheter embolization.
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Affiliation(s)
- William Salibe-Filho
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Bruna Mamprim Piloto
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Ellen Pierre de Oliveira
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Marcela Araújo Castro
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Breno Boueri Affonso
- . Serviço de Radiologia Intervencionista, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Joaquim Maurício da Motta-Leal-Filho
- . Serviço de Radiologia Intervencionista, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Edgar Bortolini
- . Serviço de Radiologia Intervencionista, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Mário Terra-Filho
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Tortora A, Riccioni ME, Gaetani E, Ojetti V, Holleran G, Gasbarrini A. Rendu-Osler-Weber disease: a gastroenterologist's perspective. Orphanet J Rare Dis 2019; 14:130. [PMID: 31174568 PMCID: PMC6555961 DOI: 10.1186/s13023-019-1107-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/27/2019] [Indexed: 12/17/2022] Open
Abstract
Hereditary hemorrhagic teleangectasia (HHT, or Rendu-Osler-Weber disease) is a rare inherited syndrome, characterized by arterio-venous malformations (AVMs or Telangiectasia). The most important and common manifestation is nose bleeds (epistaxis). The telangiectasias (small AVMs) are most evident on the lips, tongue, buccal mucosa, face, chest, and fingers, however; large arterio-venous malformations can also occur in the lungs, liver, pancreas, or brain. Telangiectasias in the upper gastrointestinal tract are known to occur, however data regarding possible small-bowel involvement is limited due to technical difficulties in visualizing the entire gastrointestinal tract. The occurrence of AVMs in the stomach and small bowel can result in chronic bleeding and anaemia. Less frequently, this may occur due to bleeding from oesophageal varices, as patients with HHT can develop hepatic parenchymal AVMs or vascular shunts which cause hepatic cirrhosis and portal hypertension. Gastroenterologists have a crucial role in the management of these patients, however difficulties remain in the detection and management of complications of HHT in the gastrointestinal tract.
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Affiliation(s)
- Annalisa Tortora
- Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy. .,Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Maria Elena Riccioni
- Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
| | - Eleonora Gaetani
- Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
| | - Veronica Ojetti
- Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
| | - Grainne Holleran
- Department of Clinical Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - Antonio Gasbarrini
- Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
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Schelker RC, Andorfer K, Putz F, Herr W, Jung EM. Identification of two distinct hereditary hemorrhagic telangiectasia patient subsets with different hepatic perfusion properties by combination of contrast-enhanced ultrasound (CEUS) with perfusion imaging quantification. PLoS One 2019; 14:e0215178. [PMID: 30973932 PMCID: PMC6459476 DOI: 10.1371/journal.pone.0215178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/27/2019] [Indexed: 12/27/2022] Open
Abstract
Background Hereditary hemorrhagic telangiectasia (HHT) is marked by arteriovenous fusion comprising hepatic vascular malformations (HVaMs) with the chance of bleeding. Aims We investigated HVaMs in HHT patients by combination of contrast-enhanced ultrasound (CEUS) with perfusion imaging quantification to be able to sub-classify a high risk cohort of asymptomatic HHT patients. Methods The imaging characteristics on CEUS in 34 patients (aged 21–84 years; mean 58.9) with HHT were retrospectively evaluated. Real-time contrast harmonic imaging, sulfur hexafluoride-filled microbubbles and motion adjustment were utilized. Cine loops of the liver were digital stored, perfusion was quantified using a software reading DICOM data`s. Results HVaMs were diagnosed in 31 out of 34 patients. Significant uppermost peak enhancement (PE), wash-in area under the curve (WiAUC) and wash-in perfusion index (WiPI) were identified in the shunt region (100%), next in the hilar region (PE 32.6%; WiAUC 33.9%; WiPI 34.1%), and the lowest in the hepatic parenchyma (PE 10.2%; WiAUC 12.0%; WiPI 9.5%). The perfusion parameters in the shunt region compared to the other regions were significantly increased in one subgroup of patients. Consistent with this, the intrahepatic portal vein diameter and Buscarini grading was significantly higher, while portal vein peak velocity was significantly lower in this patient subset. By statistical analysis, we could correlate PE and WiPI to these clinical parameters, while WiAUC showed no clinical association. Conclusions For the first time we combined CEUS findings with motion adjustment software to quantitative determine perfusion parameters of a cohort of HHT patients. Hereby, we could identify a subset of HHT patients with two markedly increased parameter values in the shunt region compared to the hilus/hepatic parenchyma. This could contribute to sub-classify a high-risk group of HHT patients with therapeutic indication.
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Affiliation(s)
- Roland C. Schelker
- Department of Internal Medicine III, Hematology & Oncology, University Hospital of Regensburg, Regensburg, Germany
- * E-mail:
| | - Kornelia Andorfer
- Department of Ear-Nose-Throat, University Hospital of Regensburg, Regensburg, Germany
| | - Franz Putz
- Department of Nephrology, University Hospital of Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, Hematology & Oncology, University Hospital of Regensburg, Regensburg, Germany
| | - Ernst-Michael Jung
- Department of Radiology, University Hospital of Regensburg, Regensburg, Germany
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Lactulose to the Rescue: A Case of Toxic Hepatic Encephalopathy Caused by Portosystemic Shunting and Epistaxis in a Patient with Hereditary Hemorrhagic Telangiectasia. Case Reports Hepatol 2019; 2019:7573408. [PMID: 31032126 PMCID: PMC6457288 DOI: 10.1155/2019/7573408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/14/2019] [Indexed: 12/31/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an uncommon autosomal dominant disorder characterized by telangiectasias and arteriovenous malformations. Multiple organ systems are involved including the skin, lungs, gastrointestinal tract, and brain. Hepatic encephalopathy is an extremely rare complication of HHT and early diagnosis and treatment can be life-saving. We present a rare case of hepatic encephalopathy caused by HHT-induced portosystemic shunting treated with lactulose.
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Abstract
PURPOSE OF REVIEW Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disease characterized by telangiectasia and arteriovenous malformations (AVMs). To date, five genetic types of HHT and one combined juvenile polyposis syndrome and HHT are known. Clinical and genetic screening of patients suspected with HHT is recommended to confirm the diagnosis and to prevent complications associated with HHT. The aim of this article is to give an overview of the evidence and to formulate a recommendation for clinicians concerning screening for HHT. RECENT FINDINGS Complications of HHT such as stroke, brain abscess and intracranial hemorrhage are caused by pulmonary and cerebral AVMs (CAVMs) and can often be prevented by screening and treatment when possible. Screening and treatment of these AVMs will result in an increased life expectancy comparable with that of the general population as opposed to unscreened and untreated HHT patients. SUMMARY Screening of HHT patients and their first-degree relatives is recommended to prevent severe complications including stroke, brain abscess and intracranial hemorrhage.
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Aagaard KS, Kjeldsen AD, Tørring PM, Green A. Comorbidity among HHT patients and their controls in a 20 years follow-up period. Orphanet J Rare Dis 2018; 13:223. [PMID: 30547819 PMCID: PMC6295040 DOI: 10.1186/s13023-018-0962-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 11/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background Hereditary Haemorrhagic Telangiectasia (HHT) is an autosomal dominant genetic disorder with a wide variety of clinical manifestations due to the presence of multiple arteriovenous malformations in various tissues and organs. Objective To study the need for hospital admittance in a group of HHT patients and matched controls during a 20 years follow-up period commencing in 1995. Methods All HHT patients in the County of Funen, Denmark, were included. For each patient, three age and sex matched controls were identified at the time of enrolment. Data on all hospitalisations were extracted from the national health registers and compared with clinical records. The hospitalisations were grouped as HHT relevant or not HHT relevant based on the discharge diagnosis (International Classification of Diseases, ICD10) and with particular focus on infections, bleedings and thromboembolic events. Patients with HHT were compared with controls concerning the first time incidence of each discharge diagnosis. Results We included 73 HHT patients and 219 controls of which one control was lost to follow-up. HHT-patients had significantly more hospitalisations per person caused by infections in joints and bones, but not caused by infections in general. Bleeding episodes were, as expected, more frequent among the HHT-patients. The study revealed a similar incidence of abscesses and thromboembolisms, including in the central nervous system, among the HHT patients and controls. Conclusions Based on this study Danish HHT patients had an increased comorbidity of infections in joints and bones and of bleeding episodes. However, the incidence of thromboembolisms, cerebral abscesses and other conditions commonly considered related to HHT was comparable between the patients and the controls. The patients included in this study were closely monitored at a highly specialised HHT Centre where they received relevant diagnostic evaluation, treatment and counselling. Since this is assumed to benefit the overall health of the patients, it may explain why these patients were less prone to comorbidity than other studies have suggested. Electronic supplementary material The online version of this article (10.1186/s13023-018-0962-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katrine Saldern Aagaard
- Danish HHT Center OUH, Department of Otorhinolaryngology, Odense University Hospital, 5000, Odense C, Denmark.
| | - Anette Drøhse Kjeldsen
- Danish HHT Center OUH, Department of Otorhinolaryngology, Odense University Hospital, 5000, Odense C, Denmark. .,Clinical institute University of Southern Denmark, Odense, Denmark.
| | | | - Anders Green
- Odense Patient data Explorative Network (OPEN), Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Riera-Mestre A, Mora Luján J, Sanchez Martínez R, Torralba Cabeza M, Patier de la Peña J, Juyol Rodrigo M, Lopez Wolf D, Ojeda Sosa A, Monserrat L, López Rodríguez M, Alonso Cotoner C, Beneyto Florido M, Fernández A, Gil Sánchez R, García Morillo J, Gómez Cerezo J, Gómez del Olmo V, Iglesias P, Juyol Rodrigo M, Lopez Osle N, López Rodríguez M, López Wolf D, Moreno de la Santa García M, Ojeda Sosa A, Patier de la Peña J, Perez Garcia M, Riera-Mestre A, Sánchez Martínez R, Torralba Cabeza M, Zarrabeitia Puente R. Computerized registry of patients with hemorrhagic hereditary telangiectasia (RiHHTa registry) in Spain: Objectives, methods, and preliminary results. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Medical management of haemorrhagic hereditary telangiectasia in adult patients. Med Clin (Barc) 2018; 152:274-280. [PMID: 30502301 DOI: 10.1016/j.medcli.2018.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/26/2022]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant inherited Rare Disease that causes a systemic anomalous vascular overgrowth. The approach and follow-up of these patients should be from multidisciplinary units. Its diagnosis is carried out according to Curaçao clinical Criteria. Telangiectasia in the nasal mucosa cause recurrent epistaxis, the main symptom of HHT and difficult to control. The three types of hepatic shunting, hepatic artery to hepatic vein, hepatic artery to portal vein or to portal vein to hepatic vein, can cause high-output heart failure, portal hypertension or porto-systemic encephalopathy, respectively. These types of vascular involvement can be established using computerised tomography. Pulmonary arteriovenous fistula should be screened for all HHT patients by contrast echocardiography. The main objective is to review the management of epistaxis, liver and lung involvement of the adult patient with HHT.
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Hereditary Hemorrhagic Telangiectasia: Time Not Only to Recognize the Disease but Also to Prioritize the Symptomatic Patient on the Waiting List. Transplantation 2018; 103:1302-1303. [PMID: 30335700 DOI: 10.1097/tp.0000000000002492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Haghighat L, Brandt EJ, Proctor DD, Garcia-Tsao G, Pollak J, Young LH. Evolution of Intrahepatic Shunts in a Patient With Hereditary Hemorrhagic Telangiectasia. Ann Intern Med 2018; 169:508-509. [PMID: 29868721 DOI: 10.7326/l18-0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Leila Haghighat
- Yale New Haven Hospital, New Haven, Connecticut (L.H., E.J.B., D.D.P., G.G., J.P., L.H.Y.)
| | - Eric J Brandt
- Yale New Haven Hospital, New Haven, Connecticut (L.H., E.J.B., D.D.P., G.G., J.P., L.H.Y.)
| | - Deborah D Proctor
- Yale New Haven Hospital, New Haven, Connecticut (L.H., E.J.B., D.D.P., G.G., J.P., L.H.Y.)
| | - Guadalupe Garcia-Tsao
- Yale New Haven Hospital, New Haven, Connecticut (L.H., E.J.B., D.D.P., G.G., J.P., L.H.Y.)
| | - Jeffrey Pollak
- Yale New Haven Hospital, New Haven, Connecticut (L.H., E.J.B., D.D.P., G.G., J.P., L.H.Y.)
| | - Lawrence H Young
- Yale New Haven Hospital, New Haven, Connecticut (L.H., E.J.B., D.D.P., G.G., J.P., L.H.Y.)
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Riera-Mestre A, Mora Luján JM, Sanchez Martínez R, Torralba Cabeza MA, Patier de la Peña JL, Juyol Rodrigo MC, Lopez Wolf D, Ojeda Sosa A, Monserrat L, López Rodríguez M. Computerized registry of patients with hemorrhagic hereditary telangiectasia (RiHHTa Registry) in Spain: Objectives, methods, and preliminary results. Rev Clin Esp 2018; 218:468-476. [PMID: 30177223 DOI: 10.1016/j.rce.2018.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/08/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Hereditary hemorrhagic telangiectasia (HHT) is a rare disease with autosomal dominant inheritance that causes systemic vascular affectation. MATERIAL AND METHOD After development a multicentric Spanish national registry, called RiHHTa, main clinical manifestations and diagnostic procedures of the first patients introduced are described. RESULTS 141 patients were included, of which 91 (64.5%) were women. The mean age at diagnosis was 42 years. Mutations in the ACVRL1 gene predominated over the ENG gene. The initial symptom was recurrent epistaxis in 130 (92.2%) patients and in three (2.1%), brain abscess. Pulmonary arteriovenous (AV) fistula were detected in 36 (45%) of the 79 patients who underwent thoracic CT angiography. The contrast echocardiography detected very few bubbles (grade I) or none, in 36 (45%) of these 79 affected patients. In 43 (67.2%) of the 64 patients with an abdominal CT angiography, hepatic vascular malformations were detected, mostly telangiectasias, AV and arterio-portal fistula, and extrahepatic in 14 (10%) subjects. More than half of the patients were screened for the presence of brain arteriovenous malformations which was found in 3.9% of them. The upper part of the intestinal tube was the most (95%) affected region. CONCLUSION The RiHHTa Registry allows improving the management of patients with HHT. An inadequate use of thoracic CT angiography and the usefulness of abdominal CT angiography has been detected in order to define subtypes of hepatic vascular involvement and detect extrahepatic vascular involvement.
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Affiliation(s)
- A Riera-Mestre
- Unidad de Telangiectasia Hemorrágica Hereditaria, Servicio de Medicina Interna, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, España; Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, España; Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna.
| | - J M Mora Luján
- Unidad de Telangiectasia Hemorrágica Hereditaria, Servicio de Medicina Interna, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, España; Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna
| | - R Sanchez Martínez
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital General Universitario de Alicante, Alicante, España
| | - M A Torralba Cabeza
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J L Patier de la Peña
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, España
| | - M C Juyol Rodrigo
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, España
| | - D Lopez Wolf
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - A Ojeda Sosa
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Insular Universitario de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España
| | - L Monserrat
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Health in Code, A Coruña, España
| | - M López Rodríguez
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Central de la Cruz Roja, Madrid, España
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