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Fish A, Wang D, Knight E, Pollak J, Schlachter T. Recurrence of Pulmonary Arteriovenous Malformation after Embolization in Patients with Pulmonary Hypertension. J Vasc Interv Radiol 2024; 35:1148-1153. [PMID: 38692392 DOI: 10.1016/j.jvir.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE To evaluate the correlation between pulmonary hypertension (PH) and recurrence of pulmonary arteriovenous malformation (PAVM) after embolization. MATERIALS AND METHODS With institutional review board (IRB) approval, the records of 377 patients with PAVMs evaluated at a single hereditary hemorrhagic telangiectasia (HHT) center of excellence between January 1, 2013, and September 10, 2023, were retrospectively reviewed. PAVMs embolized during this time period were evaluated for recurrence. Patients and PAVMs not treated during this time period were excluded. Growth of previously untreated PAVMs was not considered recurrence. Patients without chest computed tomography (CT) follow-up were excluded. General demographics, HHT status as defined by genetic testing or Curacao criteria, presence of PH, history of smoking, anemia, and hepatic arteriovenous malformations (AVMs) were documented. Odds ratio (OR) was calculated and stratified analysis was performed to assay the correlation between PAVM recurrence, PH, and possible confounders. RESULTS A total of 151 patients with PAVMs were treated during the study period, including 438 PAVMs, for which follow-up was available. This included 106 patients with definite, 31 with doubtful, and 14 with possible HHT. The presence of PH was significantly associated with PAVM recurrence both by patient (OR, 8.13; 95% CI, 3.50-19.67) and by lesion (OR, 4.07; 95% CI, 2.14-7.91). Multivariate analysis demonstrated that this correlation was independent of several variables including HHT status, smoking history, presence of hepatic AVMs, and anemia. CONCLUSIONS There is a high correlation between PH and PAVM recurrence, suspected to be due to high pulmonary artery pressures causing recanalization. PH may suggest the need for shorter surveillance intervals.
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Affiliation(s)
- Adam Fish
- Department of Interventional Radiology, Yale School of Medicine, New Haven, Connecticut.
| | - Daniel Wang
- Department of Interventional Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth Knight
- Department of Interventional Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey Pollak
- Department of Interventional Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Todd Schlachter
- Department of Interventional Radiology, Yale School of Medicine, New Haven, Connecticut
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2
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Gatts J, Chandra SR, Ricci K. Medical Management and Therapeutic Updates on Vascular Anomalies of the Head and Neck: Part 2. Oral Maxillofac Surg Clin North Am 2024; 36:115-123. [PMID: 37981343 DOI: 10.1016/j.coms.2023.09.012] [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] [Indexed: 11/21/2023]
Abstract
Discovery of inherited and somatic genetic mutations, along with advancements in clinical and scientific research, has improved understanding of vascular anomalies and changed the treatment paradigm. With aim of minimizing need for invasive procedures and improving disease outcomes, molecularly targeted medications and anti-angiogenesis agents have become important as both adjuncts to surgery, and increasingly, as the primary treatment of vascular anomalies. This article highlights the commonly used and emerging therapeutic medications for non-malignant vascular tumors and vascular malformations in addition to medical management of associated hematologic abnormalities.
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Affiliation(s)
- Jorie Gatts
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Srinivasa R Chandra
- Department of Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR, USA.
| | - Kiersten Ricci
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA
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3
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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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4
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Chen J, Zhang B. Application of contrast-enhanced ultrasound in hemothorax of hereditary hemorrhagic telangiectasia: A case report and literature review. Clin Hemorheol Microcirc 2022; 83:273-278. [PMID: 36565108 DOI: 10.3233/ch-221646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hereditary hemorrhagic telangiectasis (HHT) is an autosomal dominant hereditary disease, which can lead to abnormal angiogenesis. We performed contrast-enhanced ultrasound (CEUS) in a patient with HHT represented with hemothorax. After targeted embolization, the condition of hemothorax improved. In this case, we explore the use of CEUS to locate the responsible vessel of hemothorax, and found that CEUS could be used as a complementary preoperative method of localization with Computed tomography angiography (CTA).
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Affiliation(s)
- Jie Chen
- Department of Ultrasound, China-Japan Friendship Hospital, Beijing, China
| | - Bo Zhang
- Department of Ultrasound, China-Japan Friendship Hospital, Beijing, China
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5
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Hyldahl SJ, El‐Jaji MQ, Schuster A, Kjeldsen AD. Skin and mucosal telangiectatic lesions in hereditary hemorrhagic telangiectasia patients. Int J Dermatol 2022; 61:1497-1505. [PMID: 35792874 PMCID: PMC9796122 DOI: 10.1111/ijd.16320] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 05/19/2022] [Accepted: 06/13/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The diagnostic criteria for hereditary hemorrhagic telangiectasia (HHT) include the presence of telangiectatic lesions in common sites (nose, fingers, oral cavity, and lips). Telangiectatic lesions are described as red spots in the skin, but this description is inadequate. Few studies have investigated the characteristics of telangiectatic lesions in HHT, and we aimed to describe the distribution and morphology of telangiectatic lesions in HHT patients. METHODS We reviewed the telangiectatic lesions in 34 adult HHT patients seen at our HHT center. Photo documentation was used to describe the morphology and distribution of the lesions. RESULTS The telangiectatic lesions in both HHT1 and HHT2 patients were predominantly round and either flat or slightly elevated. However, elongated flat lesions and larger round, elevated lesions were also observed. Patients with HHT1 had more lesions in the mucosa (tongue and oral cavity) compared with HHT2 patients. There was no difference between HHT1 and HHT2 patients in the total number of lesions in the skin and mucosa. CONCLUSIONS The typical round, flat telangiectatic lesion is the most common lesion in HHT, but it is very often accompanied by elevated or elongated lesions. The total number of lesions did not vary between gender, but women had significantly more lesions in the mucosa (p = 0.027). The presentation of telangiectatic lesions may vary a little between HHT1 and HHT2 patients but not in such a way that allows the morphology and location of the lesions to predict the HHT subtype.
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Affiliation(s)
- Stefanie J. Hyldahl
- Department of ORL – Head & Neck Surgery and AudiologyOdense University Hospital, HHT‐Center OUHOdense CDenmark
| | - Mounir Q. El‐Jaji
- Department of ORL – Head & Neck Surgery and AudiologyOdense University Hospital, HHT‐Center OUHOdense CDenmark,University of Southern DenmarkOdenseDenmark
| | - Annette Schuster
- Department of DermatologyOdense University HospitalOdense CDenmark
| | - Anette Drøhse Kjeldsen
- Department of ORL – Head & Neck Surgery and AudiologyOdense University Hospital, HHT‐Center OUHOdense CDenmark,University of Southern DenmarkOdenseDenmark,VASCERN European Reference Network of Rare DiseasesParisDenmark
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6
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Drapé E, Anquetil T, Larrivée B, Dubrac A. Brain arteriovenous malformation in hereditary hemorrhagic telangiectasia: Recent advances in cellular and molecular mechanisms. Front Hum Neurosci 2022; 16:1006115. [PMID: 36504622 PMCID: PMC9729275 DOI: 10.3389/fnhum.2022.1006115] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/27/2022] [Indexed: 11/25/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a genetic disorder characterized by vessel dilatation, such as telangiectasia in skin and mucosa and arteriovenous malformations (AVM) in internal organs such as the gastrointestinal tract, lungs, and brain. AVMs are fragile and tortuous vascular anomalies that directly connect arteries and veins, bypassing healthy capillaries. Mutations in transforming growth factor β (TGFβ) signaling pathway components, such as ENG (ENDOGLIN), ACVRL1 (ALK1), and SMAD4 (SMAD4) genes, account for most of HHT cases. 10-20% of HHT patients develop brain AVMs (bAVMs), which can lead to vessel wall rupture and intracranial hemorrhages. Though the main mutations are known, mechanisms leading to AVM formation are unclear, partially due to lack of animal models. Recent mouse models allowed significant advances in our understanding of AVMs. Endothelial-specific deletion of either Acvrl1, Eng or Smad4 is sufficient to induce AVMs, identifying endothelial cells (ECs) as primary targets of BMP signaling to promote vascular integrity. Loss of ALK1/ENG/SMAD4 signaling is associated with NOTCH signaling defects and abnormal arteriovenous EC differentiation. Moreover, cumulative evidence suggests that AVMs originate from venous ECs with defective flow-migration coupling and excessive proliferation. Mutant ECs show an increase of PI3K/AKT signaling and inhibitors of this signaling pathway rescue AVMs in HHT mouse models, revealing new therapeutic avenues. In this review, we will summarize recent advances and current knowledge of mechanisms controlling the pathogenesis of bAVMs, and discuss unresolved questions.
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Affiliation(s)
- Elise Drapé
- Centre de Recherche, CHU St. Justine, Montréal, QC, Canada,Département de Pharmacologie et de Physiologie, Université de Montréal, Montréal, QC, Canada
| | - Typhaine Anquetil
- Centre de Recherche, CHU St. Justine, Montréal, QC, Canada,Département De Pathologie et Biologie Cellulaire, Université de Montréal, Montréal, QC, Canada
| | - Bruno Larrivée
- Département d’Ophtalmologie, Université de Montréal, Montréal, QC, Canada,Centre De Recherche, Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada,*Correspondence: Bruno Larrivée,
| | - Alexandre Dubrac
- Centre de Recherche, CHU St. Justine, Montréal, QC, Canada,Département De Pathologie et Biologie Cellulaire, Université de Montréal, Montréal, QC, Canada,Département d’Ophtalmologie, Université de Montréal, Montréal, QC, Canada,Alexandre Dubrac,
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7
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Khedr A, Mahmoud EE, Attallah N, Mir M, Boike S, Rauf I, Jama AB, Mushtaq H, Surani S, Khan SA. Role of octreotide in small bowel bleeding. World J Clin Cases 2022; 10:9192-9206. [PMID: 36159407 PMCID: PMC9477697 DOI: 10.12998/wjcc.v10.i26.9192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/30/2022] [Accepted: 08/15/2022] [Indexed: 02/05/2023] Open
Abstract
Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients’ lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding. Small bowel bleeding is the least common cause of gastrointestinal bleeding. However, it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation. A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding. This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis. In this review article, we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.
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Affiliation(s)
- Anwar Khedr
- Department of Internal Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | | | - Noura Attallah
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Mikael Mir
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Sydney Boike
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Ibtisam Rauf
- Department of Medicine, St. George School of Medicine, Grenada, West Indies
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Hisham Mushtaq
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University Health Science Center, Bryan, TX 77807, United States
| | - Syed A Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
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8
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Kaufman CS, McDonald J, Balch H, Whitehead K. Pulmonary Arteriovenous Malformations: What the Interventional Radiologist Should Know. Semin Intervent Radiol 2022; 39:261-270. [PMID: 36062221 PMCID: PMC9433162 DOI: 10.1055/s-0042-1751260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Pulmonary arteriovenous malformations (PAVMs) are abnormal connections between the pulmonary artery and pulmonary vein bypassing the normal capillary bed causing a right-to-left shunt. The majority (80-90%) of PAVMs are associated with hereditary hemorrhagic telangiectasia (HHT). PAVMs may be asymptomatic or present with symptoms of hypoxia, shortness of breath, migraines, sequelae of paradoxical embolization, or rupture. Transcatheter embolization has become the standard of care. This article will review the clinical presentation, workup, genetics, imaging findings, embolization, complications, and follow-up for patients with PAVMs.
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Affiliation(s)
- Claire S. Kaufman
- Dotter Department of Interventional Radiology, Pacific Northwest HHT Center of Excellence, Oregon Health & Sciences University, Portland, Oregon
| | - Jamie McDonald
- Department of Pathology, University of Utah, Salt Lake City, Utah
| | - Heather Balch
- HHT Center of Excellence, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Kevin Whitehead
- HHT Center of Excellence, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
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9
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Kolarich AR, Solomon AJ, Bailey C, Latif MA, Rowan NR, Galiatsatos P, Weiss CR. Imaging Manifestations and Interventional Treatments for Hereditary Hemorrhagic Telangiectasia. Radiographics 2021; 41:2157-2175. [PMID: 34723698 DOI: 10.1148/rg.2021210100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Hemorrhagic hereditary telangiectasia (HHT) is a rare autosomal dominant disorder that causes multisystem vascular malformations including mucocutaneous telangiectasias and arteriovenous malformations (AVMs). Clinical and genetic screening of patients with signs, symptoms, or a family history suggestive of HHT is recommended to confirm the diagnosis on the basis of the Curaçao criteria and prevent associated complications. Patients with HHT frequently have epistaxis and gastrointestinal bleeding from telangiectasias. Pulmonary AVMs are common right-to-left shunts between pulmonary arteries and veins that can result in dyspnea and exercise intolerance, heart failure, migraine headaches, stroke or transient ischemic attacks, brain abscesses, or in rare cases, pulmonary hemorrhage. Primary neurologic complications from cerebral AVMs, which can take on many forms, are less common but particularly severe complications of HHT. Multimodality imaging, including transthoracic echocardiography, Doppler US, CT, and MRI, is used in the screening and initial characterization of vascular lesions in patients with HHT. Diagnostic angiography is an important tool in characterization of and interventional treatments for HHT, particularly those in the lungs and central nervous system. A multidisciplinary approach to early diagnosis, treatment, imaging, and surveillance at high-volume HHT Centers of Excellence is recommended. Although a variety of idiopathic, traumatic, or genetic conditions can result in similar clinical and imaging features, the Curaçao criteria are particularly useful for the proper diagnosis of HHT. Imaging and treatment options are reviewed, with a focus on screening, diagnosis, and posttreatment findings, with the use of updated international guidelines. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Andrew R Kolarich
- From the Russell H. Morgan Department of Radiology and Radiological Science (A.R.K., A.J.S., C.B., M.A.L., C.R.W.), Department of Otolarygology-Head and Neck Surgery (N.R.R.), and Department of Medicine, Division of Pulmonology (P.G.), The Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD 21287
| | - Alex J Solomon
- From the Russell H. Morgan Department of Radiology and Radiological Science (A.R.K., A.J.S., C.B., M.A.L., C.R.W.), Department of Otolarygology-Head and Neck Surgery (N.R.R.), and Department of Medicine, Division of Pulmonology (P.G.), The Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD 21287
| | - Christopher Bailey
- From the Russell H. Morgan Department of Radiology and Radiological Science (A.R.K., A.J.S., C.B., M.A.L., C.R.W.), Department of Otolarygology-Head and Neck Surgery (N.R.R.), and Department of Medicine, Division of Pulmonology (P.G.), The Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD 21287
| | - Muhammad Aamir Latif
- From the Russell H. Morgan Department of Radiology and Radiological Science (A.R.K., A.J.S., C.B., M.A.L., C.R.W.), Department of Otolarygology-Head and Neck Surgery (N.R.R.), and Department of Medicine, Division of Pulmonology (P.G.), The Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD 21287
| | - Nicholas R Rowan
- From the Russell H. Morgan Department of Radiology and Radiological Science (A.R.K., A.J.S., C.B., M.A.L., C.R.W.), Department of Otolarygology-Head and Neck Surgery (N.R.R.), and Department of Medicine, Division of Pulmonology (P.G.), The Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD 21287
| | - Panagis Galiatsatos
- From the Russell H. Morgan Department of Radiology and Radiological Science (A.R.K., A.J.S., C.B., M.A.L., C.R.W.), Department of Otolarygology-Head and Neck Surgery (N.R.R.), and Department of Medicine, Division of Pulmonology (P.G.), The Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD 21287
| | - Clifford R Weiss
- From the Russell H. Morgan Department of Radiology and Radiological Science (A.R.K., A.J.S., C.B., M.A.L., C.R.W.), Department of Otolarygology-Head and Neck Surgery (N.R.R.), and Department of Medicine, Division of Pulmonology (P.G.), The Johns Hopkins University School of Medicine, 1800 Orleans St, Sheikh Zayed Tower, Baltimore, MD 21287
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10
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Incidence of Spontaneous Pulmonary AVM Rupture in HHT Patients. J Clin Med 2021; 10:jcm10204714. [PMID: 34682838 PMCID: PMC8540859 DOI: 10.3390/jcm10204714] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022] Open
Abstract
The spontaneous rupture of pulmonary AVMs, resulting in pulmonary hemorrhage and hydrothorax, is a life-threatening complication. While this phenomenon has been previously reported, the true incidence is not yet known. This study retrospectively reviewed records of 801 HHT patients with pulmonary AVMs to identify a single lifetime episode of hemothorax or pulmonary hemorrhage secondary to pulmonary AVM rupture. The lifetime prevalence and incidence of pulmonary AVM rupture in HHT patients was 2.7% and 0.16% respectively. In these patients, AVM rupture represented the initial presentation of HHT in nine (40.9%) cases and was life-threatening in nine (40.9%) cases. All cases occurred in virgin lesions, and subsequent embolization was curative. While a feared complication, pulmonary AVM rupture is rare and is likely effectively prevented by existing embolization techniques and indications.
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11
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Gulay KCM, Nagata N, Aoshima K, Shiohara N, Kobayashi A, Takiguchi M, Kimura T. Peliosis Hepatis with Chylous Ascites in a Dog. J Comp Pathol 2021; 187:63-67. [PMID: 34503655 DOI: 10.1016/j.jcpa.2021.07.001] [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: 03/30/2021] [Revised: 05/15/2021] [Accepted: 07/05/2021] [Indexed: 02/07/2023]
Abstract
A 6-year-old spayed female Toy Poodle dog was referred to the Hokkaido University Veterinary Teaching Hospital for abdominal distension. Abdominocentesis yielded ascitic fluid that had a mildly increased total protein concentration and a 2.7-fold higher triglyceride concentration than plasma, and was interpreted as chylous ascites. The patient had an enlarged liver, which contained multiple, small, nodular masses and cyst-like structures. Microscopically, these lesions were multifocal dilated spaces containing lymphocytes, endothelial cells, fibrin and islands of hepatocytes. Increased α-smooth muscle actin-positive cells were observed in hepatic sinusoids. Based on these findings, we diagnosed peliosis hepatis with chylous ascites, which is likely to have been due to lymphangiectasia and disrupted hepatic sinusoids. Neither Bartonella spp DNA nor mutations in ACVRL1 and MTM1 genes were detected, although there was a 47-fold increase in hepatic ACVRL1 expression compared with age-matched control liver. To the authors' knowledge, this is the first report of chylous ascites resulting from peliosis hepatis in any species.
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Affiliation(s)
- Kevin Christian Montecillo Gulay
- Laboratory of Comparative Pathology, Department of Clinical Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Noriyuki Nagata
- Veterinary Teaching Hospital, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Keisuke Aoshima
- Laboratory of Comparative Pathology, Department of Clinical Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan.
| | - Nozomi Shiohara
- Laboratory of Internal Medicine, Department of Clinical Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Atsushi Kobayashi
- Laboratory of Comparative Pathology, Department of Clinical Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Mitsuyoshi Takiguchi
- Veterinary Teaching Hospital, Hokkaido University, Sapporo, Hokkaido, Japan; Laboratory of Internal Medicine, Department of Clinical Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Takashi Kimura
- Laboratory of Comparative Pathology, Department of Clinical Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
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12
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Thresholds of Endoglin Expression in Endothelial Cells Explains Vascular Etiology in Hereditary Hemorrhagic Telangiectasia Type 1. Int J Mol Sci 2021; 22:ijms22168948. [PMID: 34445652 PMCID: PMC8396348 DOI: 10.3390/ijms22168948] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 12/24/2022] Open
Abstract
Hereditary Hemorrhagic Telangiectasia type 1 (HHT1) is an autosomal dominant inherited disease characterized by arteriovenous malformations and hemorrhage. HHT1 is caused by mutations in ENDOGLIN, which encodes an ancillary receptor for Transforming Growth Factor-β/Bone Morphogenetic Protein-9 expressed in all vascular endothelial cells. Haploinsufficiency is widely accepted as the underlying mechanism for HHT1. However, it remains intriguing that only some, but not all, vascular beds are affected, as these causal gene mutations are present in vasculature throughout the body. Here, we have examined the endoglin expression levels in the blood vessels of multiple organs in mice and in humans. We found a positive correlation between low basal levels of endoglin and the general prevalence of clinical manifestations in selected organs. Endoglin was found to be particularly low in the skin, the earliest site of vascular lesions in HHT1, and even undetectable in the arteries and capillaries of heterozygous endoglin mice. Endoglin levels did not appear to be associated with organ-specific vascular functions. Instead, our data revealed a critical endoglin threshold compatible with the haploinsufficiency model, below which endothelial cells independent of their tissue of origin exhibited abnormal responses to Vascular Endothelial Growth Factor. Our results support the development of drugs promoting endoglin expression as potentially protective.
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13
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Hetts SW, Shieh JT, Ohliger MA, Conrad MB. Hereditary Hemorrhagic Telangiectasia: The Convergence of Genotype, Phenotype, and Imaging in Modern Diagnosis and Management of a Multisystem Disease. Radiology 2021; 300:17-30. [PMID: 33973836 DOI: 10.1148/radiol.2021203487] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease that manifests as vascular malformations in the brain, lung, liver, gastrointestinal tract, nasal mucosa, and skin. Diagnosis and management of HHT is guided in large part by imaging studies, making it a condition with which the radiology community needs familiarity. Proper screening and care lead to improved morbidity and mortality in patients with HHT. International guidelines were recently updated and form the basis for a detailed discussion of the role of imaging and image-guided therapy in HHT. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Steven W Hetts
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Joseph T Shieh
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Michael A Ohliger
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
| | - Miles B Conrad
- From the Department of Radiology and Biomedical Imaging (S.W.H., M.O., M.C.), HHT Center of Excellence (S.W.H., J.S., M.O., M.C.), and Department of -Pediatrics (J.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628
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14
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Major T, Gindele R, Balogh G, Bárdossy P, Bereczky Z. Founder Effects in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2021; 10:jcm10081682. [PMID: 33919892 PMCID: PMC8070971 DOI: 10.3390/jcm10081682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 12/26/2022] Open
Abstract
A founder effect can result from the establishment of a new population by individuals from a larger population or bottleneck events. Certain alleles may be found at much higher frequencies because of genetic drift immediately after the founder event. We provide a systematic literature review of the sporadically reported founder effects in hereditary hemorrhagic telangiectasia (HHT). All publications from the ACVRL1, ENG and SMAD4 Mutation Databases and publications searched for terms “hereditary hemorrhagic telangiectasia” and “founder” in PubMed and Scopus, respectively, were extracted. Following duplicate removal, 141 publications were searched for the terms “founder” and “founding” and the etymon “ancest”. Finally, 67 publications between 1992 and 2020 were reviewed. Founder effects were graded upon shared area of ancestry/residence, shared core haplotypes, genealogy and prevalence. Twenty-six ACVRL1 and 12 ENG variants with a potential founder effect were identified. The bigger the cluster of families with a founder mutation, the more remarkable is its influence to the populational ACVRL1/ENG ratio, affecting HHT phenotype. Being aware of founder effects might simplify the diagnosis of HHT by establishing local genetic algorithms. Families sharing a common core haplotype might serve as a basis to study potential second-hits in the etiology of HHT.
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Affiliation(s)
- Tamás Major
- Division of Otorhinolaryngology and Head & Neck Surgery, Kenézy Gyula Campus, University of Debrecen Medical Center, H-4031 Debrecen, Hungary
- Correspondence: (T.M.); (Z.B.); Tel.: +36-52-511777/1756 (T.M.); +36-52-431956 (Z.B.); Fax: +36-52-511755 (T.M.); +36-52-340011 (Z.B.)
| | - Réka Gindele
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (R.G.); (G.B.)
| | - Gábor Balogh
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (R.G.); (G.B.)
| | - Péter Bárdossy
- Hungarian Heraldry and Genealogical Society, H-1014 Budapest, Hungary;
| | - Zsuzsanna Bereczky
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary; (R.G.); (G.B.)
- Correspondence: (T.M.); (Z.B.); Tel.: +36-52-511777/1756 (T.M.); +36-52-431956 (Z.B.); Fax: +36-52-511755 (T.M.); +36-52-340011 (Z.B.)
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15
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Mutational and phenotypic characterization of hereditary hemorrhagic telangiectasia. Blood 2021; 136:1907-1918. [PMID: 32573726 DOI: 10.1182/blood.2019004560] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/17/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular dysplasia. Care delivery for HHT patients is impeded by the need for laborious, repeated phenotyping and gaps in knowledge regarding the relationships between causal DNA variants in ENG, ACVRL1, SMAD4 and GDF2, and clinical manifestations. To address this, we analyzed DNA samples from 183 previously uncharacterized, unrelated HHT and suspected HHT cases using the ThromboGenomics high-throughput sequencing platform. We identified 127 rare variants across 168 heterozygous genotypes. Applying modified American College of Medical Genetics and Genomics Guidelines, 106 variants were classified as pathogenic/likely pathogenic and 21 as nonpathogenic (variant of uncertain significance/benign). Unlike the protein products of ACVRL1 and SMAD4, the extracellular ENG amino acids are not strongly conserved. Our inferences of the functional consequences of causal variants in ENG were therefore informed by the crystal structure of endoglin. We then compared the accuracy of predictions of the causal gene blinded to the genetic data using 2 approaches: subjective clinical predictions and statistical predictions based on 8 Human Phenotype Ontology terms. Both approaches had some predictive power, but they were insufficiently accurate to be used clinically, without genetic testing. The distributions of red cell indices differed by causal gene but not sufficiently for clinical use in isolation from genetic data. We conclude that parallel sequencing of the 4 known HHT genes, multidisciplinary team review of variant calls in the context of detailed clinical information, and statistical and structural modeling improve the prognostication and treatment of HHT.
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16
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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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17
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Genotype-Phenotype Correlations in Children with HHT. J Clin Med 2020; 9:jcm9092714. [PMID: 32842615 PMCID: PMC7565052 DOI: 10.3390/jcm9092714] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), a rare autosomal dominant disease mostly caused by mutations in three known genes (ENG, ACVRL1, and SMAD4), is characterized by the development of vascular malformations (VMs). Patients with HHT may present with mucocutaneous telangiectasia, as well as organ arteriovenous malformations (AVMs) of the central nervous system, lungs, and liver. Genotype-phenotype correlations have been well described in adults with HHT. We aimed to investigate genotype-phenotype correlations among pediatric HHT patients. Demographic, clinical, and genetic data were collected and analyzed in 205 children enrolled in the multicenter Brain Vascular Malformation Consortium HHT Project. A chi-square test was used to determine the association between phenotypic presentations and genotype. Among 205 patients (age range: 0-18 years; mean: 11 years), ENG mutation was associated with the presence of pulmonary AVMs (p < 0.001) and brain VM (p < 0.001). The presence of a combined phenotype-defined as both pulmonary AVMs and brain VMs-was also associated with ENG mutation. Gastrointestinal bleeding was rare (4.4%), but was associated with SMAD4 genotype (p < 0.001). We conclude that genotype-phenotype correlations among pediatric HHT patients are similar to those described among adults. Specifically, pediatric patients with ENG mutation have a greater prevalence of pulmonary AVMs, brain VMs, and a combined phenotype.
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18
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Eker OF, Boccardi E, Sure U, Patel MC, Alicante S, Alsafi A, Coote N, Droege F, Dupuis O, Fialla AD, Jones B, Kariholu U, Kjeldsen AD, Lefroy D, Lenato GM, Mager HJ, Manfredi G, Nielsen TH, Pagella F, Post MC, Rennie C, Sabbà C, Suppressa P, Toerring PM, Ugolini S, Buscarini E, Dupuis-Girod S, Shovlin CL. European Reference Network for Rare Vascular Diseases (VASCERN) position statement on cerebral screening in adults and children with hereditary haemorrhagic telangiectasia (HHT). Orphanet J Rare Dis 2020; 15:165. [PMID: 32600364 PMCID: PMC7322871 DOI: 10.1186/s13023-020-01386-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/22/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a multisystemic vascular dysplasia inherited as an autosomal dominant trait. Approximately 10 % of patients have cerebral vascular malformations, a proportion being cerebral arteriovenous malformations (AVMs) and fistulae that may lead to potentially devastating consequences in case of rupture. On the other hand, detection and treatment related-risks are not negligible, and immediate. While successful treatment can be undertaken in individual cases, current data do not support the treatment of unruptured AVMs, which also present a low risk of bleeding in HHT patients. Screening for these AVMs is therefore controversial. Structured discussions, distinctions of different cerebrovascular abnormalities commonly grouped into an “AVM” bracket, and clear guidance by neurosurgical and neurointerventional radiology colleagues enabled the European Reference Network for Rare Vascular Disorders (VASCERN-HHT) to develop the following agreed Position Statement on cerebral screening: 1) First, we emphasise that neurological symptoms suggestive of cerebral AVMs in HHT patients should be investigated as in general neurological and emergency care practice. Similarly, if an AVM is found accidentally, management approaches should rely on expert discussions on a case-by-case basis and individual risk-benefit evaluation of all therapeutic possibilities for a specific lesion. 2) The current evidence base does not favour the treatment of unruptured cerebral AVMs, and therefore cannot be used to support widespread screening of asymptomatic HHT patients. 3) Individual situations encompass a wide range of personal, cultural and clinical states. In order to enable informed patient choice, and avoid conflicting advice, particularly arising from non-neurovascular interpretations of the evidence base, we suggest that all HHT patients should have the opportunity to discuss knowingly brain screening issues with their healthcare provider. 4) Any screening discussions in asymptomatic individuals should be preceded by informed pre-test review of the latest evidence regarding preventative and therapeutic efficacies of any interventions. The possibility of harm due to detection of, or intervention on, a vascular malformation that would not have necessarily caused any consequence in later life should be stated explicitly. We consider this nuanced Position Statement provides a helpful, evidence-based framework for informed discussions between healthcare providers and patients in an emotionally charged area.
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Affiliation(s)
- Omer F Eker
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - Edoardo Boccardi
- Niguarda Hospital, Milan, Italy and VASCERN HHT Reference Centre, Crema, Italy
| | - Ulrich Sure
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany
| | - Maneesh C Patel
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Saverio Alicante
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | - Ali Alsafi
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Nicola Coote
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Freya Droege
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany
| | - Olivier Dupuis
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France
| | - Annette Dam Fialla
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Bryony Jones
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Ujwal Kariholu
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Anette D Kjeldsen
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - David Lefroy
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Gennaro M Lenato
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy
| | - Hans Jurgen Mager
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Guido Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | - Troels H Nielsen
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Fabio Pagella
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Marco C Post
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Catherine Rennie
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK
| | - Carlo Sabbà
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy.
| | - Patrizia Suppressa
- VASCERN HHT Reference Centre, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Policlinico, Bari, Italy
| | - Pernille M Toerring
- VASCERN HHT Reference Centre, Odense Universitetshospital, Syddansk Universitet, Odense, Denmark
| | - Sara Ugolini
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | | | - Claire L Shovlin
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK and Imperial College London, London, UK.
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19
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Andersen PE, Duvnjak S, Gerke O, Kjeldsen AD. Long-Term Single-Center Retrospective Follow-Up After Embolization of Pulmonary Arteriovenous Malformations Treated Over a 20-year Period: Frequency of Re-canalization with Various Embolization Materials and Clinical Outcome. Cardiovasc Intervent Radiol 2019; 42:1102-1109. [DOI: 10.1007/s00270-019-02204-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/10/2019] [Indexed: 10/27/2022]
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20
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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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21
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Karlsson T, Cherif H. Mutations in the ENG, ACVRL1, and SMAD4 genes and clinical manifestations of hereditary haemorrhagic telangiectasia: experience from the Center for Osler's Disease, Uppsala University Hospital. Ups J Med Sci 2018; 123:153-157. [PMID: 30251589 PMCID: PMC6198721 DOI: 10.1080/03009734.2018.1483452] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM The aim of this retrospective single-centre study was to evaluate whether mutations in the ENG, ACVRL1, and SMAD4 genes were associated with different phenotypes in hereditary haemorrhagic telangiectasia (HHT). METHODS The case records of 21 HHT patients with verified mutations in ENG, ACVRL1, or SMAD4 genes were reviewed. The numbers of HHT diagnostic criteria fulfilled for the three genotypes were compared, as was the prevalence of complications such as iron deficiency anaemia, gastrointestinal haemorrhage, stroke, and cerebral abscess. RESULTS Our results indicate that mutations in the ENG (HHT1), ACVRL1 (HHT2), and SMAD4 genes result in different HHT phenotypes. Epistaxis debuts earlier and may be more severe in HHT1 than in HHT2. The prevalence of pulmonary arteriovenous malformations (AVM) is higher in HHT type 1, whereas hepatic AVMs are more common in HHT2. One patient with mutations in both ENG and ACVRL1 genes was identified, as were two SMAD4-mutated patients suffering from the overlapping juvenile polyposis-HHT syndrome. Nearly one in five patients in our HHT population has been diagnosed with stroke or cerebral abscess, indicating a high prevalence of cerebral complications. CONCLUSION Our results showing that ENG and ACVRL1 gene mutations result in different HHT phenotypes confirm the results from other HHT centres worldwide. Cerebral complications of HHT are common, underscoring the importance of regular screening for pulmonary AVMs and early intervention against such AVMs. We have identified an HHT patient with simultaneous mutations in the ENG and ACVRL1 genes. Surprisingly, this patient has had a mild course of the disease.
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Affiliation(s)
- Torbjörn Karlsson
- Department of Haematology, Uppsala University Hospital, Uppsala, Sweden
- Center for Osler’s Disease, Uppsala University Hospital, Uppsala, Sweden
- Department of Medicine, Västmanlands Hospital, Västerås, Sweden
- CONTACT Torbjörn Karlsson Department of Haematology, Uppsala University Hospital, 751 85Uppsala, Sweden
| | - Honar Cherif
- Department of Haematology, Uppsala University Hospital, Uppsala, Sweden
- Center for Osler’s Disease, Uppsala University Hospital, Uppsala, Sweden
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22
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Andersen PE, Tørring PM, Duvnjak S, Gerke O, Nissen H, Kjeldsen AD. Pulmonary arteriovenous malformations: a radiological and clinical investigation of 136 patients with long-term follow-up. Clin Radiol 2018; 73:951-957. [PMID: 30086858 DOI: 10.1016/j.crad.2018.07.096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/05/2018] [Indexed: 11/19/2022]
Abstract
AIM To assess the clinical outcome of patients with and without hereditary haemorrhagic telangiectasia (HHT) after embolisation of pulmonary arteriovenous malformations (PAVM) from a single national centre. MATERIALS AND METHODS The present register-based observational study including all patients with PAVM treated with embolisation at a reference centre for HHT and PAVM was undertaken over a 20-year period. Demographic data, HHT genotyping, clinical presentation, and outcome were registered. Patients with HHT were compared to the patients without HHT. Clinical examination, contrast-enhanced echocardiography, and computed tomography (CT) were used to assess the clinical outcome at follow-up. RESULTS One hundred and thirty-six patients with 339 PAVM underwent embolisation during the study period: 22 did not have HHT; 62% had HHT1, 10% had HHT2, 4% had JP-HHT, 8% had clinical HHT without identified genetic mutations. Solitary PAVM were more common among patients without HHT than with HHT. Mean follow-up after the first embolisation was 58 months. Mean age at first embolisation was 46.5 years, and at last follow-up 51.8 years. The clinical success without shunt at follow-up was 87%. The 30-day mortality related to the embolisation was 0%. Twenty patients died during follow-up (mean age 69 years). Most patients could be treated during one session, but many will need a long follow-up with repeated clinical examinations and embolisation. CONCLUSION The majority of patients referred for embolisation of PAVM had HHT. Multiple PAVM is associated with HHT. Patients with PAVM should be screened for HHT and patients with HHT for PAVM. Embolisation is a safe procedure with high clinical success.
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Affiliation(s)
- P E Andersen
- Department of Radiology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern, Denmark.
| | - P M Tørring
- Department of Clinical Genetics, Odense University Hospital, Denmark
| | - S Duvnjak
- Department of Radiology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern, Denmark
| | - O Gerke
- Department of Nuclear Medicine, Odense University Hospital, Denmark; Department of Biostatistics, University of Southern, Denmark
| | - H Nissen
- Department of Cardiology, Odense University Hospital, Denmark
| | - A D Kjeldsen
- Department of Clinical Research, University of Southern, Denmark; Department of Otorhinolaryngology Head and Neck Surgery, Odense University Hospital, Denmark
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23
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Abstract
Liver vascular malformations (VMs) in hereditary hemorrhagic telangiectasia (HHT) are typically diffuse and can evolve from small telangiectasias to large arteriovenous malformations, with various stages of severity. Doppler US is the ideal first-line investigation for the assessment of liver VMs in HHT due to its safety, tolerability, low costs, and accuracy for the detection of liver VMs. The caliber, course, and flow characteristics in the hepatic artery, portal vein, and hepatic vein as determined by Doppler US, together with parenchymal abnormalities, support the diagnosis of liver VMs in HHT and their severity staging. When Doppler US expertise is lacking or an assessment of HHT patients with symptoms/signs suggestive of complicated liver VMs is required, particularly if OLT is considered, multiphase CT or MRI is suitable to investigate symptomatic liver VMs. Liver biopsy is neither necessary for the diagnosis of hepatic VMs related to HHT nor should be considered in HHT patients with liver mass/es suggestive of focal nodular hyperplasia.
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Gamboa NT, Joyce EJ, Eli I, Park MS, Taussky P, Schmidt RH, McDonald J, Whitehead KJ, Kalani MYS. Clinical presentation and treatment paradigms of brain arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia. J Clin Neurosci 2018; 51:22-28. [PMID: 29483005 DOI: 10.1016/j.jocn.2018.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 01/08/2018] [Indexed: 11/25/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is characterized by recurrent spontaneous epistaxis, mucocutaneous telangiectases, and multisystem arteriovenous malformations (AVMs). Brain AVMs typically present at birth and are identified in approximately 10-20% of patients with HHT. A retrospective review was undertaken of all HHT patients with known single or multiple brain AVMs treated at our institution. Thirty-nine patients with brain AVM(s) were diagnosed with HHT. Most patients presented with at least one Curaçao criterion. A total of 78 brain AVMs were identified in 39 patients. Two-thirds of patients had solitary brain AVMs, whereas 33% of patients harbored at least two lesions (range: 2-16). Brain AVMs of the supratentorial cerebral hemispheres comprised 83% of all lesions, whereas infratentorial lesions accounted for only 17%. Of the 55 brain AVMs assigned Spetzler-Martin grading, the majority of patients were Grade 1 (73%), and 23% and 4% were Grades 2 and 3, respectively. Patients were treated with surgery alone (51%), embolization alone (6%), embolization followed by surgery (9%), stereotactic radiosurgery (11%), stereotactic radiosurgery followed by surgery (3%), or observation (20%). Of patients who underwent genetic analysis, 62% possessed mutations in ENG (HHT type 1), whereas 38% had mutations in ACVRL1 (HHT type 2). This robust patient cohort of brain AVMs in 39 patients with HHT advances the collective understanding of this disease's varied presentation, diagnostic workup, genetic underpinnings, and available treatment options.
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Affiliation(s)
- Nicholas T Gamboa
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Evan J Joyce
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ilyas Eli
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Min S Park
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Richard H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States; University of Utah Hereditary Hemorrhagic Telangiectasia Center of Excellence, Salt Lake City, UT, United States
| | - Jamie McDonald
- University of Utah Hereditary Hemorrhagic Telangiectasia Center of Excellence, Salt Lake City, UT, United States
| | - Kevin J Whitehead
- University of Utah Hereditary Hemorrhagic Telangiectasia Center of Excellence, Salt Lake City, UT, United States
| | - M Yashar S Kalani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, UT, United States; University of Utah Hereditary Hemorrhagic Telangiectasia Center of Excellence, Salt Lake City, UT, United States.
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Impact of Age on Outcomes in Hospitalized Patients with Hereditary Hemorrhagic Telangiectasia. Adv Hematol 2018; 2018:4798425. [PMID: 29610574 PMCID: PMC5828469 DOI: 10.1155/2018/4798425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/01/2017] [Accepted: 01/15/2018] [Indexed: 11/17/2022] Open
Abstract
Background There is little published literature regarding the impact of age on outcomes amongst hospitalized HHT (hereditary hemorrhagic telangiectasia) patients. Methods The Nationwide Inpatient Sample (NIS) was used to obtain data on all hospital discharges occurring in HHT patients from 2000 to 2012. The association between admission age and HHT-related complications and outcomes were studied. Results 10293 hospitalizations in HHT patients from 2000 to 2012 were included. Patients > 50 accounted for 77% of all admissions with 30% of admissions occurring in the 51–65 age group. Bleeding related complications were the most frequent (62.7%, n = 6455 hospitalizations), followed by cardiovascular (41%, n = 4216), neurological (12.4%, n = 1276), and hepatobiliary (6.4%, n = 660) complications. Patients older than 50 accounted for 83% of bleeding events, 90% of cardiovascular events, 58% of neurologic events, and 81% of hepatobiliary events. The vast majority (83%) of medical and surgical procedures were performed in those older than 50 years of age. Older patients also experienced higher rates of death. Conclusion Aging has significant adverse impacts on rates of hospitalization, complications, and outcomes amongst HHT patients in the United States. Except for neurologic complications, the vast majority of this disease burden is borne by patients older than 50 years.
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Characterization of pulmonary arteriovenous malformations in ACVRL1 versus ENG mutation carriers in hereditary hemorrhagic telangiectasia. Genet Med 2017; 20:639-644. [DOI: 10.1038/gim.2017.160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 08/11/2017] [Indexed: 11/08/2022] Open
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Gastrointestinal Manifestations of Hereditary Hemorrhagic Telangiectasia (HHT): A Systematic Review of the Literature. Dig Dis Sci 2017; 62:2623-2630. [PMID: 28836046 PMCID: PMC5641264 DOI: 10.1007/s10620-017-4719-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 08/09/2017] [Indexed: 12/28/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also called Osler-Weber-Rendu syndrome, is an autosomal dominant genetic disease that affects the vasculature of numerous organs. The prevalence of HHT is estimated to be between 1.5 and 2 persons per 10,000. While there is still much to learn about this condition, there is an increasing understanding its underlying pathophysiology, genetic basis, presentations, and management. Recognizing that the clinical manifestations of HHT can involve a number of organ systems will provide clinicians with a higher index of suspicion for the disease. This early diagnosis and genotyping can greatly reduce mortality for a patient with HHT through appropriate screening for complications. This review will focus on the gastrointestinal manifestations of HHT and how these can dictate treatment and prognosis.
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Hosman AE, de Gussem EM, Balemans WAF, Gauthier A, Westermann CJJ, Snijder RJ, Post MC, Mager JJ. Screening children for pulmonary arteriovenous malformations: Evaluation of 18 years of experience. Pediatr Pulmonol 2017; 52:1206-1211. [PMID: 28407366 DOI: 10.1002/ppul.23704] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/22/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disease with multi-systemic vascular dysplasia. Early diagnosis through screening is important to prevent serious complications. How best to screen children of affected parents for pulmonary arteriovenous malformations (PAVMs) is often subject to debate. Transthoracic contrast echocardiogram (TTCE) is considered optimal in screening for PAVMs in adults. Guidelines for the screening of children are not specific, reflecting the lack of scientific evidence on the best method to use. OBJECTIVE Aims of this study are (i) to evaluate our current screening method, consisting of history, physical examination, pulse oximetry, and chest radiography and (ii) to assess whether postponing more invasive screening for PAVMs until adulthood is safe. METHODS This is a prospective observational cohort study using a patient database. RESULTS Over a period of 18 years (mean follow-up 9.21 years, SD 4.72 years), 436 children from HHT families were screened consecutively. A total of 175/436 (40%) children had a diagnosis of HHT. PAVMs were detected in 39/175 (22%) children, 33/39 requiring treatment by embolotherapy. None of the screened children suffered any PAVM-associated complications with this screening method. CONCLUSION This study shows that a conservative screening method during childhood is sufficient to detect large PAVMs and protect children with HHT for PAVM-related complications. Postponing TTCE and subsequent chest CT scanning until adulthood to detect any smaller PAVMs does not appear to be associated with major risk.
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Affiliation(s)
- Anna E Hosman
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Els M de Gussem
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Andréanne Gauthier
- Department of Pulmonology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Cees J J Westermann
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Repke J Snijder
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marco C Post
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes J Mager
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
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Kjeldsen A, Aagaard KS, Tørring PM, Möller S, Green A. 20-year follow-up study of Danish HHT patients-survival and causes of death. Orphanet J Rare Dis 2016; 11:157. [PMID: 27876060 PMCID: PMC5120428 DOI: 10.1186/s13023-016-0533-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/07/2016] [Indexed: 11/17/2022] Open
Abstract
Background Hereditary Haemorrhagic Telangiectasia (HHT) is a dominantly inheritable disorder, with a wide variety of clinical manifestations due to presence of multiple arteriovenous manifestations. The most common mutations are found in HHT1 (ENG) and HHT2 (ACVRL1) patients, causing alterations in the TGF-β pathway which is responsible for angiogenesis. Modulations of angiogenesis may influence cancer rates. The objective of the study was to evaluate 20-year survival according to HHT subtype, as well as to evaluate differences in causes of death comparing HHT patients and controls. We also wanted to investigate whether cancer morbidity among HHT patients differs from that among controls. Results We included all HHT patients in the County of Fyn, Denmark, prevalent as of January 1st 1995 in total 73 HHT patients. In addition three age- and sex- matched controls per HHT patient were evaluated, in total 218 controls (one was lost due to registration failure). The controls were defined at start of follow-up in 1995. Information on lifestyle factors was not available. A total of 32 (44%) HHT patients and 97 (44%) controls passed away during follow-up. The survival curves were evenly distributed showing similar survival rates in the two groups. Cancer diagnoses had been registered in the follow-up period in 4 (5%) HHT patients and in 38 (17%) controls. Conclusion The mortality was not increased among Danish HHT patients compared to controls. This study is based on a clinical unselected series of HHT patients with the whole spectrum of severity, independent of need for medical care. Our data also suggest that HHT patients to a lesser degree than the background population are affected by cancer. Electronic supplementary material The online version of this article (doi:10.1186/s13023-016-0533-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anette Kjeldsen
- HHT-center OUH, Department of Otorhinolaryngology, Odense, Denmark. .,Clinical Institute, University of Southern Denmark, Odense, Denmark.
| | | | | | - Sören Möller
- OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Anders Green
- OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Arthur H, Geisthoff U, Gossage JR, Hughes CCW, Lacombe P, Meek ME, Oh P, Roman BL, Trerotola SO, Velthuis S, Wooderchak-Donahue W. Executive summary of the 11th HHT international scientific conference. Angiogenesis 2016; 18:511-24. [PMID: 26391603 DOI: 10.1007/s10456-015-9482-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a hereditary condition that results in vascular malformations throughout the body, which have a proclivity to rupture and bleed. HHT has a worldwide incidence of about 1:5000 and approximately 80 % of cases are due to mutations in ENG, ALK1 (aka activin receptor-like kinase 1 or ACVRL1) and SMAD4. Over 200 international clinicians and scientists met at Captiva Island, Florida from June 11-June 14, 2015 to present and discuss the latest research on HHT. 156 abstracts were accepted to the meeting and 60 were selected for oral presentations. The first two sections of this article present summaries of the basic science and clinical talks. Here we have summarized talks covering key themes, focusing on areas of agreement, disagreement, and unanswered questions. The final four sections summarize discussions in the Workshops, which were theme-based topical discussions led by two moderators. We hope this overview will educate as well as inspire those within the field and from outside, who have an interest in the science and treatment of HHT.
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MESH Headings
- Activin Receptors, Type II/genetics
- Activin Receptors, Type II/metabolism
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Congresses as Topic
- Endoglin
- Humans
- Receptors, Cell Surface/genetics
- Receptors, Cell Surface/metabolism
- Smad4 Protein/genetics
- Smad4 Protein/metabolism
- Telangiectasia, Hereditary Hemorrhagic/genetics
- Telangiectasia, Hereditary Hemorrhagic/metabolism
- Telangiectasia, Hereditary Hemorrhagic/pathology
- Telangiectasia, Hereditary Hemorrhagic/therapy
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Affiliation(s)
- Helen Arthur
- Institute of Genetic Medicine, Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Urban Geisthoff
- Department of Otorhinolaryngology, Essen University Hospital, Essen, Germany
| | - James R Gossage
- Department of Medicine, Georgia Regents University, Augusta, GA, USA.
| | - Christopher C W Hughes
- Department of Molecular Biology and Biochemistry, University of California Irvine, Irvine, CA, USA
| | - Pascal Lacombe
- Department of Diagnostic and Interventional Radiology, Hôpital Ambroise Paré, Université de Versailles, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France
| | - Mary E Meek
- Department of Interventional Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Paul Oh
- Department of Physiology and Functional Genomics, University of Florida College of Medicine, Gainesville, FL, USA
| | - Beth L Roman
- Department of Human Genetics and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott O Trerotola
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sebastiaan Velthuis
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Whitney Wooderchak-Donahue
- ARUP Institute for Clinical and Experimental Pathology, Department of Pathology, University of Utah, Salt Lake City, UT, USA
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Brinjikji W, Iyer VN, Yamaki V, Lanzino G, Cloft HJ, Thielen KR, Swanson KL, Wood CP. Neurovascular Manifestations of Hereditary Hemorrhagic Telangiectasia: A Consecutive Series of 376 Patients during 15 Years. AJNR Am J Neuroradiol 2016; 37:1479-86. [PMID: 27012295 DOI: 10.3174/ajnr.a4762] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 01/28/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hereditary hemorrhagic telangiectasia is associated with a wide range of neurovascular abnormalities. The aim of this study was to characterize the spectrum of cerebrovascular lesions, including brain arteriovenous malformations, in patients with hereditary hemorrhagic telangiectasia and to study associations between brain arteriovenous malformations and demographic variables, genetic mutations, and the presence of AVMs in other organs. MATERIALS AND METHODS Consecutive patients with definite hereditary hemorrhagic telangiectasia who underwent brain MR imaging/MRA, CTA, or DSA at our institution from 2001 to 2015 were included. All studies were re-evaluated by 2 senior neuroradiologists for the presence, characteristics, location, and number of brain arteriovenous malformations, intracranial aneurysms, and nonshunting lesions. Brain arteriovenous malformations were categorized as high-flow pial fistulas, nidus-type brain AVMs, and capillary vascular malformations and were assigned a Spetzler-Martin score. We examined the association between baseline clinical and genetic mutational status and the presence/multiplicity of brain arteriovenous malformations. RESULTS Three hundred seventy-six patients with definite hereditary hemorrhagic telangiectasia were included. One hundred ten brain arteriovenous malformations were noted in 48 patients (12.8%), with multiple brain arteriovenous malformations in 26 patients. These included 51 nidal brain arteriovenous malformations (46.4%), 58 capillary vascular malformations (52.7%), and 1 pial arteriovenous fistula (0.9%). Five patients (10.4%) with single nidal brain arteriovenous malformation presented with hemorrhage. Of brain arteriovenous malformations, 88.9% (88/99) had a Spetzler-Martin score of ≤2. Patients with brain arteriovenous malformations were more likely to be female (75.0% versus 57.6%, P = .01) and have a family history of hereditary hemorrhagic telangiectasia (95.8% versus 84.8%, P = .04). The prevalence of brain arteriovenous malformation was 19.7% in endoglin (ENG) mutations and 12.5% in activin receptor-like kinase (1ACVRL1) mutations. CONCLUSIONS Our study of 376 patients with hereditary hemorrhagic telangiectasia demonstrated a high prevalence of brain arteriovenous malformations. Nidal brain arteriovenous malformations and capillary vascular malformations occurred in roughly equal numbers.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B., H.J.C., K.R.T., C.P.W.)
| | - V N Iyer
- Pulmonary and Critical Care Medicine (V.N.I., V.Y.)
| | - V Yamaki
- Pulmonary and Critical Care Medicine (V.N.I., V.Y.)
| | - G Lanzino
- Neurosurgery (G.L.), Mayo Clinic, Rochester, Minnesota
| | - H J Cloft
- From the Departments of Radiology (W.B., H.J.C., K.R.T., C.P.W.)
| | - K R Thielen
- From the Departments of Radiology (W.B., H.J.C., K.R.T., C.P.W.)
| | - K L Swanson
- Department of Pulmonary and Critical Care Medicine (K.L.S.), Mayo Clinic, Scottsdale, Arizona
| | - C P Wood
- From the Departments of Radiology (W.B., H.J.C., K.R.T., C.P.W.)
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Abstract
OBJECTIVE To determine whether patients with hereditary haemorrhagic telangiectasia were being screened according to international guidelines, and to review recent evidence in order to provide up-to-date guidelines for the initial systemic management of hereditary haemorrhagic telangiectasia. METHODS A retrospective case note analysis was conducted, assessing patients in terms of screening for: genetics, cerebral arteriovenous malformations, pulmonary and hepatic arteriovenous malformations, and gastrointestinal telangiectasia. Databases searched included Medline, the Cumulative Index to Nursing and Allied Health Literature, and Embase. RESULTS Screening investigations were most frequently performed for hepatic arteriovenous malformations and least frequently for genetics. Recent data suggest avoiding routine genetic and cerebral arteriovenous malformation screening because of treatment morbidities; performing high-resolution chest computed tomography for pulmonary arteriovenous malformation screening; using capsule endoscopy (if possible) to reduce complications from upper gastrointestinal endoscopy; and omitting routine liver enzyme testing in favour of Doppler ultrasound. CONCLUSION Opportunities for systemic arteriovenous malformation screening are frequently overlooked. This review highlights the need for screening and considers the form in which it should be undertaken.
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Shovlin C, Awan I, Cahilog Z, Abdulla F, Guttmacher A. Reported cardiac phenotypes in hereditary hemorrhagic telangiectasia emphasize burdens from arrhythmias, anemia and its treatments, but suggest reduced rates of myocardial infarction. Int J Cardiol 2016; 215:179-85. [DOI: 10.1016/j.ijcard.2016.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/02/2016] [Indexed: 01/17/2023]
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34
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de Gussem EM, Edwards CP, Hosman AE, Westermann CJJ, Snijder RJ, Faughnan ME, Mager JJ. Life expextancy of parents with Hereditary Haemorrhagic Telangiectasia. Orphanet J Rare Dis 2016; 11:46. [PMID: 27102204 PMCID: PMC4841052 DOI: 10.1186/s13023-016-0427-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/17/2016] [Indexed: 11/28/2022] Open
Abstract
Background Hereditary Haemorrhagic Telangiectasia (HHT) is an autosomal dominant disease associated with epistaxis, arteriovenous malformations and telangiectasias. Disease complications may result in premature death. Method We investigated life-expectancies of parents of HHT patients compared with their non-HHT partners using self- or telephone-administered questionnaires sent to their children. Patients were extracted from the databases of 2 participating HHT Centres: the Toronto HHT Database (Toronto, Canada) and the St. Antonius Hospital HHT Database (Nieuwegein, The Netherlands). Results Two hundred twenty five/407 (55 %) of respondents were included creating HHT- (n = 225) and control groups (n = 225) of equal size. Two hundred thirteen/225 (95 %) of the HHT group had not been screened for organ involvement of the disease prior to death. The life expectancy in parents with HHT was slightly lower compared to parents without (median age at death 73.3 years in patients versus 76.6 years in controls, p0.018). Parents with ACVRL 1 mutations had normal life expectancies, whereas parents with Endoglin mutations died 7.1 years earlier than controls (p = 0.024). Women with Endoglin mutations lived a median of 9.3 years shorter than those without (p = 0.04). Seven/123 (5 %) of deaths were HHT related with a median age at death of 61.5 years (IQ range 54.4–67.7 years). Conclusion Our study showed that the life expectancy of largely unscreened HHT patients was lower than people without HHT. Female patients with Endoglin mutations were most strikingly at risk of premature death from complications. These results emphasize the importance of referring patients with HHT for screening of organ involvement and timely intervention to prevent complications.
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Affiliation(s)
- E M de Gussem
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - C P Edwards
- Department of Medicine, Division of Respirology, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - A E Hosman
- Department of Medicine, Division of Respirology, St Michael's Hospital, University of Toronto, Toronto, Canada. .,Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands.
| | - C J J Westermann
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - R J Snijder
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M E Faughnan
- Department of Medicine, Division of Respirology, St Michael's Hospital, University of Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - J J Mager
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
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Jonker L. TGF-β & BMP receptors endoglin and ALK1: overview of their functional role and status as antiangiogenic targets. Microcirculation 2015; 21:93-103. [PMID: 25279424 DOI: 10.1111/micc.12099] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 10/05/2013] [Indexed: 12/18/2022]
Abstract
The formation of new blood vessels from existing vasculature, angiogenesis, is facilitated through a host of different signaling processes. Members of the TGF-β superfamily, TGF-β1, TGF-β3, and BMP9, are key propagators of both inhibition and initiation of angiogenesis. HHT, characterized by AVM and capillary bed defects, is caused by germline mutations in the ENG and ACVRL1/ALK1 genes, respectively. Clinical symptoms include epistaxis and GI hemorrhage. The membranous receptors endoglin and ALK1 activate proliferation and migration of endothelial cells during the angiogenic process via the downstream intracellular SMAD signaling pathway. Endothelial cell senescence or activation is dependent on the type of cytokine, ligand concentration, cell-cell interaction, and a multitude of other signaling molecules. Endoglin and ALK1 receptor levels in tumor vasculature correlate inversely with prognosis in humans, whereas in mice, endoglin deficiency decelerates tumor progression. Therefore, endoglin and ALK1 have been identified as potential therapeutic targets for antibody treatment in various cancers. Early phase clinical trials in humans are currently underway to evaluate the efficacy and safety of biological therapy targeting endoglin/ALK1-mediated cells signaling.
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Affiliation(s)
- Leon Jonker
- North Cumbria University Hospitals NHS Trust, Carlisle, UK
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36
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Donaldson JW, McKeever TM, Hall IP, Hubbard RB, Fogarty AW. Complications and mortality in hereditary hemorrhagic telangiectasia: A population-based study. Neurology 2015; 84:1886-93. [PMID: 25862798 DOI: 10.1212/wnl.0000000000001538] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 01/27/2015] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Studies report that the risks of significant neurologic complications (including stroke, cerebral abscess, and migraine) and hemorrhagic sequelae are high in patients with hereditary hemorrhagic telangiectasia (HHT), and that life expectancy in this cohort is reduced. However, most published cohorts derive from specialist centers, which may be susceptible to bias. METHODS We used a population-based approach to estimate the risks of developing neurologic and hemorrhagic complications of HHT, the association of a diagnosis of HHT with common cardiovascular and malignant comorbidities, and also long-term survival of those with the disease. RESULTS From a UK primary care database of 3.5 million patients (The Health Improvement Network), we identified 675 cases with a diagnosis of HHT and compared them with 6,696 controls matched by age, sex, and primary care practice. Risks of stroke (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.2-2.6), cerebral abscess (OR 30.0, CI 3.1-288), and migraine (OR 1.7, CI 1.3-2.2) were elevated over controls. Bleeding complications including epistaxis (OR 11.6, CI 9.1-14.7) and gastrointestinal hemorrhage (OR 6.1, CI 2.8-13.4) were more common in cases with HHT. Survival of cases with HHT was poorer than controls with a hazard ratio for death of 2.0 (CI 1.6-2.6) and a median age at death 3 years younger. CONCLUSIONS Patients with HHT are at substantially increased risk of serious neurologic and hemorrhagic complications of the disease. Because a diagnosis of HHT is associated with a significantly poorer survival compared with those who have no disease, evaluation of new strategies to improve clinical management is required.
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Affiliation(s)
- James W Donaldson
- From the Divisions of Epidemiology and Public Health (J.W.D., T.M.M., R.B.H., A.W.F.) and Therapeutics and Molecular Medicine (I.P.H.), University of Nottingham, UK.
| | - Tricia M McKeever
- From the Divisions of Epidemiology and Public Health (J.W.D., T.M.M., R.B.H., A.W.F.) and Therapeutics and Molecular Medicine (I.P.H.), University of Nottingham, UK
| | - Ian P Hall
- From the Divisions of Epidemiology and Public Health (J.W.D., T.M.M., R.B.H., A.W.F.) and Therapeutics and Molecular Medicine (I.P.H.), University of Nottingham, UK
| | - Richard B Hubbard
- From the Divisions of Epidemiology and Public Health (J.W.D., T.M.M., R.B.H., A.W.F.) and Therapeutics and Molecular Medicine (I.P.H.), University of Nottingham, UK
| | - Andrew W Fogarty
- From the Divisions of Epidemiology and Public Health (J.W.D., T.M.M., R.B.H., A.W.F.) and Therapeutics and Molecular Medicine (I.P.H.), University of Nottingham, UK
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37
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Garg N, Khunger M, Gupta A, Kumar N. Optimal management of hereditary hemorrhagic telangiectasia. J Blood Med 2014; 5:191-206. [PMID: 25342923 PMCID: PMC4206399 DOI: 10.2147/jbm.s45295] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known by the eponym Osler-Weber-Rendu syndrome, is a group of related disorders inherited in an autosomal dominant fashion and characterized by the development of arteriovenous malformations (AVM) in the skin, mucous membranes, and/or internal organs such as brain, lungs, and liver. Its prevalence is currently estimated at one in 5,000 to 8,000. Most cases are due to mutations in the endoglin (HHT1) or ACVRLK1 (HHT2) genes. Telangiectasias in nasal and gastrointestinal mucosa generally present with recurrent/chronic bleeding and iron deficiency anemia. Larger AVMs occur in lungs (~40%-60% of affected individuals), liver (~40%-70%), brain (~10%), and spine (~1%). Due to the devastating and potentially fatal complications of some of these lesions (for example, strokes and brain abscesses with pulmonary AVMs), presymptomatic screening and treatment are of utmost importance. However, due to the rarity of this condition, many providers lack an appreciation for the whole gamut of its manifestations and complications, age-dependent penetrance, and marked intrafamilial variation. As a result, HHT remains frequently underdiagnosed and many families do not receive the appropriate screening and treatments. This article provides an overview of the clinical features of HHT, discusses the clinical and genetic diagnostic strategies, and presents an up-to-date review of literature and detailed considerations regarding screening for visceral AVMs, preventive modalities, and treatment options.
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Affiliation(s)
- Neetika Garg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Monica Khunger
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Arjun Gupta
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nilay Kumar
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
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Saleh M, Carter MT, Latino GA, Dirks P, Ratjen F. Brain arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia: clinical presentation and anatomical distribution. Pediatr Neurol 2013; 49:445-50. [PMID: 24080277 DOI: 10.1016/j.pediatrneurol.2013.07.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 07/20/2013] [Accepted: 07/30/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia is an autosomal dominant genetic disease with a wide array of vascular malformations involving multiple organs. Brain arteriovenous malformations can lead to intracranial hemorrhage and are often diagnosed only after patients become symptomatic. Early diagnosis and interventional treatment may prevent neurologic sequelae or death. Because of the rarity of defined cases, the spectrum of presentations in children with brain arteriovenous malformations and hereditary hemorrhagic telangiectasia has not been explored in detail. Here, we report our experience in children with hereditary hemorrhagic telangiectasia and brain arteriovenous malformations regarding both disease manifestations at presentation and the spectrum of brain arteriovenous malformation manifestations. METHODS A retrospective review of demographics, clinical manifestations, and brain magnetic resonance imaging/computed tomography scan findings in 115 patients with confirmed hereditary hemorrhagic telangiectasia (HHT) was conducted using the Hospital for Sick Children's HHT Clinic database for the years 1997-2012. RESULTS Eleven patients (four girls and seven boys) were diagnosed with hereditary hemorrhagic telangiectasia and brain arteriovenous malformations during this period. Five patients initially presented with epistaxis, four presented with intracranial hemorrhage, and two were asymptomatic with a positive family history of confirmed hereditary hemorrhagic telangiectasia. Although all children had an index case with hereditary hemorrhagic telangiectasia in the family, in three patients, hereditary hemorrhagic telangiectasia was not diagnosed before the child's presentation with intracranial hemorrhage. Multiple brain arteriovenous malformations were found in five patients, with one patient having bithalamic arteriovenous malformations. CONCLUSIONS This study highlights the importance of both family history and early clinical signs to prompt further diagnostic testing to avoid intracranial hemorrhage from brain arteriovenous malformations in children with hereditary hemorrhagic telangiectasia.
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Affiliation(s)
- Maha Saleh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Division of Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
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Tørring P, Brusgaard K, Ousager L, Andersen P, Kjeldsen A. National mutation study among Danish patients with hereditary haemorrhagic telangiectasia. Clin Genet 2013; 86:123-33. [DOI: 10.1111/cge.12269] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 08/23/2013] [Accepted: 08/29/2013] [Indexed: 12/01/2022]
Affiliation(s)
- P.M. Tørring
- HHT Centre OUH, Department of Clinical Genetics
- Department of Otorhinolaryngology
| | | | | | - P.E. Andersen
- Department of Interventional Radiology; Odense University Hospital and Institute of Clinical Research, University of Southern Denmark; Odense Denmark
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Alessandrino F, Felisaz PF, La Fianza A. Peliosis hepatis associated with hereditary haemorrhagic telangiectasia. Gastroenterol Rep (Oxf) 2013; 1:203-6. [PMID: 24759967 PMCID: PMC3938001 DOI: 10.1093/gastro/got021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is an autosomal, predominantly inherited disease characterized by diffuse telangiectases involving the skin, mucous membranes, lung, brain, gastrointestinal tract and liver. Peliosis hepatis is a rare, benign disorder causing sinusoidal dilatation and the presence of multiple blood-filled lacunar spaces within the liver. We report a case of an HHT patient with incidental magnetic resonance findings of focal hepatic peliosis.
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Affiliation(s)
- F Alessandrino
- Foundation IRCCS, Policlinico San Matteo, Institute of Radiology, University of Pavia, Pavia, Italy
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41
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Prevalence of pulmonary arteriovenous malformations in children versus adults with hereditary hemorrhagic telangiectasia. J Pediatr 2013; 163:282-4. [PMID: 23522378 DOI: 10.1016/j.jpeds.2013.02.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/11/2013] [Accepted: 02/08/2013] [Indexed: 01/15/2023]
Abstract
It is unclear whether pulmonary arteriovenous malformations (PAVMs) in hereditary hemorrhagic telangiectasia develop later in life or are preformed in childhood. We show that the prevalence of PAVMs in children is similar to that in their parents, providing evidence against de novo PAVM formation in hereditary hemorrhagic telangiectasia.
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42
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Endoscopic evaluation of gastrointestinal tract in patients with hereditary hemorrhagic telangiectasia and correlation with their genotypes. Genet Med 2013; 16:3-10. [PMID: 23722869 DOI: 10.1038/gim.2013.62] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 04/09/2013] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Hereditary hemorrhagic telangiectasia (HHT) is an autosomal-dominant vascular dysplasia characterized by telangiectases and arteriovenous malformations. Three causative genes are known: ENG (HHT-1), ACVRL1 (HHT-2), and SMAD4 (mutated in HHT in association with juvenile polyposis). Gastrointestinal bleeding is the most common symptom after epistaxis. The stomach and the duodenum are the main gastrointestinal sites of telangiectases. Our aim was to explore gastrointestinal tract of consecutive HHT patients to assess distribution, number, size, and type of telangiectases in relation to genotype. METHODS HHT patients underwent gastroduodenoscopy, video capsule endoscopy, and colonoscopy. Molecular analysis of ENG and ACVRL1 was performed to identify the disease-causing mutation. RESULTS Twenty-two patients (13 men; mean age: 59 ± 9 years) were analyzed: 7 with HHT-1, 13 with HHT-2, and 2 undefined. Gastrointestinal telangiectases were identified as follows: at gastroduodenoscopy in 86% of HHT-1 patients and in 77% of HHT-2 patients, at video capsule endoscopy in all HHT-1 patients and in 84% of HHT-2 patients, and at colonoscopy in 1 patient for each group. HHT-1 showed multiple telangiectases with a higher prevalence, more relevant in the duodenum. CONCLUSION Our data demonstrate extensive involvement of the gastrointestinal tract with a more severe association in HHT-1. Gastroduodenoscopy provides significant information on gastrointestinal involvement, and video capsule endoscopy may be added in selected patients. Colonic polyps/adenomas were identified as occasional findings.
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Govani FS, Giess A, Mollet IG, Begbie ME, Jones MD, Game L, Shovlin CL. Directional next-generation RNA sequencing and examination of premature termination codon mutations in endoglin/hereditary haemorrhagic telangiectasia. Mol Syndromol 2013; 4:184-96. [PMID: 23801935 DOI: 10.1159/000350208] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 01/12/2023] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a disease characterised by abnormal vascular structures, and most commonly caused by mutations in ENG, ACVRL1 or SMAD4 encoding endothelial cell-expressed proteins involved in TGF-β superfamily signalling. The majority of mutations reported on the HHT mutation database are predicted to lead to stop codons, either due to frameshifts or direct nonsense substitutions. The proportion is higher for ENG (67%) and SMAD4 (65%) than for ACVRL1 (42%), p < 0.0001. Here, by focussing on ENG, we report why conventional views of these mutations may need to be revised. Of the 111 stop codon-generating ENG mutations, on ExPASy translation, all except one were premature termination codons (PTCs), sited at least 50-55 bp upstream of the final exon-exon boundary of the main endoglin isoform, L-endoglin. This strongly suggests that the mutated RNA species will undergo nonsense-mediated decay. We provide new in vitro expression data to support dominant negative activity of stable truncated endoglin proteins but suggest these will not generate HHT: the single natural stop codon mutation in L-endoglin (sited within 50-55 nucleotides of the final exon-exon boundary) is unlikely to generate functional protein since it replaces the entire transmembrane domain, as would 8 further natural stop codon mutations, if the minor S-endoglin isoform were implicated in HHT pathogenesis. Finally, next-generation RNA sequencing data of 7 different RNA libraries from primary human endothelial cells demonstrate that multiple intronic regions of ENG are transcribed. The potential consequences of heterozygous deletions or duplications of such regions are discussed. These data support the haploinsufficiency model for HHT pathogenesis, explain why final exon mutations have not been detected to date in HHT, emphasise the potential need for functional examination of non-PTC-generating mutations, and lead to proposals for an alternate stratification system of mutational types for HHT genotype-phenotype correlations.
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Affiliation(s)
- F S Govani
- NHLI Cardiovascular Sciences, Hammersmith Campus, Imperial College London, London, UK
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Pollak JS, White RI. Distal Cross-sectional Occlusion Is the “Key” to Treating Pulmonary Arteriovenous Malformations. J Vasc Interv Radiol 2012. [DOI: 10.1016/j.jvir.2012.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Nishida T, Faughnan ME, Krings T, Chakinala M, Gossage JR, Young WL, Kim H, Pourmohamad T, Henderson KJ, Schrum SD, James M, Quinnine N, Bharatha A, Terbrugge KG, White RI. Brain arteriovenous malformations associated with hereditary hemorrhagic telangiectasia: gene-phenotype correlations. Am J Med Genet A 2012; 158A:2829-34. [PMID: 22991266 DOI: 10.1002/ajmg.a.35622] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 07/26/2012] [Indexed: 11/06/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disease with a wide spectrum of vascular malformations (VMs) involving multiple organs. Nine to 16% of patients with HHT harbor brain arteriovenous malformations (AVMs), which can cause intracranial hemorrhage (ICH). Our objective was to study clinical manifestations of brain AVMs in patients with HHT and correlate these with the specific gene mutated. We reviewed records of 171 patients with HHT and brain AVMs. A history of ICH was found in 27% (41/152) patients, with a mean age of 26 ± 18 range, (0-68) years. All of patients with ICH were neurologically asymptomatic prior to ICH. Multiple brain AVMs were found in 23% (170/39) of patients on initial examination. Genetic test results were available in 109 (64%) patients. Mutations in ENG, ACVRL1, and SMAD4 were present in 75 (69%), 18 (17%), and 2 (2%), respectively. A history of ICH was reported in 24% of patients with an ENG mutation and 27% of patients with an ACVRL1 mutation, with a mean age of 26 ± 16 (range, 2-50) and 18 ± 21 (0-48) years, respectively. No statistically significant differences in age at first brain AVM diagnosis, prevalence of ICH history, age at ICH, or other manifestations of brain AVMs were observed among gene groups. In conclusion, no evidence for differences in brain AVM characteristics was observed among HHT gene groups, although we cannot exclude clinically important differences. Larger studies are needed to further guide brain AVM screening decisions in patients with HHT.
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Affiliation(s)
- Takeo Nishida
- Yale HHT Center, Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
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Geirdal AØ, Dheyauldeen S, Bachmann-Harildstad G, Heimdal K. Quality of life in patients with hereditary hemorrhagic telangiectasia in Norway: a population based study. Am J Med Genet A 2012; 158A:1269-78. [PMID: 22529055 DOI: 10.1002/ajmg.a.35309] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 01/25/2012] [Indexed: 01/22/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare, autosomal dominant disease characterized by the presence of recurrent epistaxis and small characteristic malformations of the peripheral blood vessels near the surface of the skin or mucosal linings. Arteriovenous malformations (AVM) of the lung, liver, and CNS are also known clinical findings. The purpose of this study was to examine quality of life (QoL) in patients with HHT in Norway. Sixty-six affected patients (39 women and 27 men) were included. QoL on overall-, health-related (HR-QoL), and disease-specific levels were measured with Cantril's Ladder (CL), Short Form 36 (SF-36), and a Symptom-specific QoL question in HHT patients (SFB-HHT-Q), respectively. Comparisons were made between patients and an age and gender adjusted normative sample from the Norwegian population (N = 990). Overall, the results reflected that several HHT disease-related variables were associated with reduced QoL on all three levels; overall QoL (CL), HR-QoL (SF36) as well as disease-specific QoL (SFB-HHT-Q), while demographic variables impacted HR-QoL in HHT patients. Compared to the normative sample, all subscales of SF36, but bodily pain, were significantly poorer in the HHT patients. HHT disease variables had the strongest association with QoL compared to demographic variables. The results substantiate that disease severity is associated with poorer QoL in this patients. Pain contributed independently to all levels of QoL.
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Ha M, Kim YJ, Kwon KA, Hahm KB, Kim MJ, Kim DK, Lee YJ, Oh SP. Gastric angiodysplasia in a hereditary hemorrhagic telangiectasia type 2 patient. World J Gastroenterol 2012; 18:1840-4. [PMID: 22553411 PMCID: PMC3332300 DOI: 10.3748/wjg.v18.i15.1840] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 01/18/2012] [Accepted: 02/08/2012] [Indexed: 02/06/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal-dominantly inherited disease that occurs in approximately one in 5000 to 8000 people. Clinical diagnosis of HHT is made when a person presents three of the following four criteria: family history, recurrent nosebleeds, mucocutaneous telangiectasis, and arteriovenous malformations (AVM) in the brain, lung, liver and gastrointestinal (GI) tract. Although epistaxis is the most common presenting symptom, AVMs affecting the lungs, brain and GI tract provoke a more serious outcome. Heterozygous mutations in endoglin, activin receptor-like kinase 1 (ACVRL1; ALK1), and SMAD4, the genes involved in the transforming growth factor-β family signaling cascade, cause HHT. We report here the case of a 63 year-old male patient who presented melena and GI bleeding episodes, proven to be caused by bleeding from multiple gastric angiodysplasia. Esophagogastroduodenoscopy revealed multiple angiodysplasia throughout the stomach. Endoscopic argon plasma coagulation was performed to control bleeding from a gastric angiodysplasia. The patient has been admitted several times with episodes of hemoptysis and hematochezia. One year ago, the patient was hospitalized due to right-sided weakness, which was caused by left basal ganglia hemorrhage as the part of HHT presentation. In family history, the patient’s mother and elder sister had died, due to intracranial hemorrhage, and his eldest son has been suffered from recurrent epistaxis for 20 years. A genetic study revealed a mutation in exon 3 of ALK1 (c.199C > T; p.Arg67Trp) in the proband and his eldest son presenting epistaxis.
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Hereditary hemorrhagic telangiectasia: an overview of diagnosis, management, and pathogenesis. Genet Med 2011; 13:607-16. [PMID: 21546842 DOI: 10.1097/gim.0b013e3182136d32] [Citation(s) in RCA: 228] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) is a disorder of development of the vasculature characterized by telangiectases and arteriovenous malformations in specific locations. It is one of most common monogenic disorders, but affected individuals are frequently not diagnosed. The most common features of the disorder, nosebleeds, and telangiectases on the lips, hands, and oral mucosa are often quite subtle. Optimal management requires an understanding of the specific presentations of these vascular malformations, especially their locations and timing during life. Telangiectases in the nasal and gastrointestinal mucosa and brain arteriovenous malformations generally present with hemorrhage. However, complications of arteriovenous malformations in the lungs and liver are generally the consequence of blood shunting through these abnormal blood vessels, which lack a capillary bed and thus result in a direct artery-to-vein connection. Mutations in at least five genes are thought to result in hereditary hemorrhagic telangiectasia, but mutations in two genes (ENG and ACVRL1/ALK1) cause approximately 85% of cases. The frequency of arteriovenous malformations in particular organs and the occurrence of certain rare symptoms are dependent on the gene involved. Molecular genetic testing is used to establish the genetic subtype of hereditary hemorrhagic telangiectasia in a clinically affected individual and family, and for early diagnosis to allow for appropriate screening and preventive treatment.
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Gludovacz K, Vlasselaer J, Mesens T, Van Holsbeke C, Van Robays J, Gyselaers W. Early neonatal complications from pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: case report and review of the literature. J Matern Fetal Neonatal Med 2011; 25:1494-8. [DOI: 10.3109/14767058.2011.629250] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Andersen PE. Poul Erik Andersen's radiological work on Osteochondrodysplasias and interventional radiology. World J Radiol 2011; 3:210-4. [PMID: 22022640 PMCID: PMC3198263 DOI: 10.4329/wjr.v3.i8.210] [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: 10/20/2010] [Revised: 04/11/2011] [Accepted: 04/18/2011] [Indexed: 02/06/2023] Open
Abstract
Poul Erik Andersen is a Professor and Interventional Radiologist at the University of Southern Denmark, Odense and Odense University Hospital, Denmark. His innovative and expertise is primarily in vascular interventions where he has introduced and developed many procedures at Odense University Hospital. His significant experience and extensive scientific work has led to many posts in the Danish Society of Interventional Radiology, the European Society of Radiology and the Cardiovascular and Interventional Radiological Society of Europe, where he is a fellow and has passed the European Board of Interventional Radiology - The European qualification in Interventional Radiology.
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