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Salibe-Filho W, Oliveira FRD, Terra-Filho M. Update on pulmonary arteriovenous malformations. J Bras Pneumol 2023; 49:e20220359. [PMID: 37132738 PMCID: PMC10171268 DOI: 10.36416/1806-3756/e20220359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/26/2023] [Indexed: 05/04/2023] Open
Abstract
This review aimed to provide an overview of pulmonary arteriovenous malformations, including the major clinical and radiological presentations, investigation, and treatment algorithm of the condition. The primary etiology of pulmonary arteriovenous malformations is hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, with mutations in the ENG gene on chromosome 9 (HHT type 1) or in the ACVRL1/ALK1 complex (HHT type 2). Epistaxis should always be evaluated when repeated, when associated with anemia, and in some cases of hypoxemia. In the investigation, contrast echocardiography and chest CT are essential for evaluating this condition. Embolization is the best treatment choice, especially for correction in cases of hypoxemia or to avoid systemic infections. Finally, disease management was addressed in special conditions such as pregnancy. CT follow-up should be performed every 3-5 years, depending on the size of the afferent and efferent vessels, and antibiotic prophylactic care should always be oriented. Ultimately, knowledge of the disease by health professionals is a crucial point for the early diagnosis of these patients in clinical practice, which can potentially modify the natural course of the disease.
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Affiliation(s)
- William Salibe-Filho
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Francini Rossetto de Oliveira
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Mario Terra-Filho
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Tessier S, Lipton BA, Ido F, Longo S, Nanda S. Pathogenesis and therapy of arteriovenous malformations: A case report and narrative review. Int J Crit Illn Inj Sci 2021; 11:167-176. [PMID: 34760664 PMCID: PMC8547675 DOI: 10.4103/ijciis.ijciis_127_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/24/2020] [Accepted: 01/05/2021] [Indexed: 12/03/2022] Open
Abstract
Arteriovenous malformations (AVMs) are abnormal communications between arteries and veins that lack intervening capillary beds. They have been described in almost every organ in the body, emerging sporadically or as part of well-described syndromes. Hereditary hemorrhagic telangiectasia (HHT) is a rare, progressive, and lifelong disease characterized by AVMs and recurrent hemorrhaging. In the last 2 decades, significant advances have been made in understanding the pathogenesis of this condition. The accumulation of knowledge has led to a natural evolution of therapy, from open surgery to endovascular procedures, and now to a role for medications in certain AVMs. Here, we review a case of HHT and describe the most up-to-date clinical practice, including diagnosis of HHT, subtypes of HHT, and medical therapy.
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Affiliation(s)
- Steven Tessier
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Brooke A Lipton
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Firas Ido
- Department of Pulmonary and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Sudip Nanda
- Department of Cardiology, St. Luke's University Health Network, Bethlehem, PA, USA
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Droege F, Dingemann J, Thangavelu K, Kuerten CHL, Dahlfrancis PM, Kaiser C, Kaster F, Zioga E, Meyer C, Lueb C, Sure U, Lang S, Geisthoff U. [Implementation and development of a center for hereditary hemorrhagic telangiectasia]. Laryngorhinootologie 2021; 100:372-381. [PMID: 33723832 DOI: 10.1055/a-1402-0543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Hereditary Hemorrhagic Telangiectasia (HHT) is a rare and systemic disorder which is characterized by recurrent epistaxis, mucocutaneous telangiectases, and visceral arteriovenous malformations (AVM). An interdisciplinary concept is recommended. MATERIAL AND METHODS We performed a retrospective review of consecutive patients who were referred to our newly established HHT Center of Excellence (HHT COE) for evaluation and treatment between April 2014 and August 2019. RESULTS A network of over 20 departments was established at the University Hospital Essen. In 261 of the 282 patients (93 %), who were referred to the hospital's COE, the HHT diagnosis was at least possible. Most patients suffered from several symptoms (epistaxis and / or telangiectasia: > 80 %, visceral involvement: 65 %) and received a variety of treatments, often in a multidisciplinary setting. Alongside this direct treatment, the COE leader manages the coordination of the center and its public relations, which involves more than 900 e-mails per year. International collaboration and exchanges of expertise within the European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN) can improve the treatment of patients with HHT particularly where these cases are complex. CONCLUSIONS An HHT COE provides an interdisciplinary network where highly specialized diagnostic and therapeutic processes can be updated and optimized continuously.
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Affiliation(s)
- Freya Droege
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Julia Dingemann
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Kruthika Thangavelu
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Gießen und Marburg - Standort Marburg, Germany
| | | | | | - Christina Kaiser
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Friederike Kaster
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Eleni Zioga
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Corinna Meyer
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Carolin Lueb
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Ulrich Sure
- Klinik für Neurochirurgie, Universitätsklinikum Essen, Germany
| | - Stephan Lang
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Urban Geisthoff
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Gießen und Marburg - Standort Marburg, Germany
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Albiñana V, Cuesta AM, de Rojas-P I, Gallardo-Vara E, Recio-Poveda L, Bernabéu C, Botella LM. Review of Pharmacological Strategies with Repurposed Drugs for Hereditary Hemorrhagic Telangiectasia Related Bleeding. J Clin Med 2020; 9:E1766. [PMID: 32517280 PMCID: PMC7356836 DOI: 10.3390/jcm9061766] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 12/18/2022] Open
Abstract
The diagnosis of hereditary hemorrhagic telangiectasia (HHT) is based on the Curaçao criteria: epistaxis, telangiectases, arteriovenous malformations in internal organs, and family history. Genetically speaking, more than 90% of HHT patients show mutations in ENG or ACVRL1/ALK1 genes, both belonging to the TGF-β/BMP9 signaling pathway. Despite clear knowledge of the symptoms and genes of the disease, we still lack a definite cure for HHT, having just palliative measures and pharmacological trials. Among the former, two strategies are: intervention at "ground zero" to minimize by iron and blood transfusions in order to counteract anemia. Among the later, along the last 15 years, three different strategies have been tested: (1) To favor coagulation with antifibrinolytic agents (tranexamic acid); (2) to increase transcription of ENG and ALK1 with specific estrogen-receptor modulators (bazedoxifene or raloxifene), antioxidants (N-acetylcysteine, resveratrol), or immunosuppressants (tacrolimus); and (3) to impair the abnormal angiogenic process with antibodies (bevacizumab) or blocking drugs like etamsylate, and propranolol. This manuscript reviews the main strategies and sums up the clinical trials developed with drugs alleviating HHT.
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Affiliation(s)
- Virginia Albiñana
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), 9 Ramiro de Maeztu Street, 28040 Madrid, Spain; (V.A.); (A.M.C.); (I.d.R.-P.); (L.R.-P.); (C.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III, 28040 Madrid, Spain
| | - Angel M. Cuesta
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), 9 Ramiro de Maeztu Street, 28040 Madrid, Spain; (V.A.); (A.M.C.); (I.d.R.-P.); (L.R.-P.); (C.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III, 28040 Madrid, Spain
| | - Isabel de Rojas-P
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), 9 Ramiro de Maeztu Street, 28040 Madrid, Spain; (V.A.); (A.M.C.); (I.d.R.-P.); (L.R.-P.); (C.B.)
| | - Eunate Gallardo-Vara
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 300 George Street, New Haven, CT 06511, USA;
| | - Lucía Recio-Poveda
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), 9 Ramiro de Maeztu Street, 28040 Madrid, Spain; (V.A.); (A.M.C.); (I.d.R.-P.); (L.R.-P.); (C.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III, 28040 Madrid, Spain
| | - Carmelo Bernabéu
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), 9 Ramiro de Maeztu Street, 28040 Madrid, Spain; (V.A.); (A.M.C.); (I.d.R.-P.); (L.R.-P.); (C.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III, 28040 Madrid, Spain
| | - Luisa María Botella
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), 9 Ramiro de Maeztu Street, 28040 Madrid, Spain; (V.A.); (A.M.C.); (I.d.R.-P.); (L.R.-P.); (C.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III, 28040 Madrid, Spain
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Robert F, Desroches-Castan A, Bailly S, Dupuis-Girod S, Feige JJ. Future treatments for hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2020; 15:4. [PMID: 31910860 PMCID: PMC6945546 DOI: 10.1186/s13023-019-1281-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022] Open
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT), also known as Rendu-Osler syndrome, is a genetic vascular disorder affecting 1 in 5000–8000 individuals worldwide. This rare disease is characterized by various vascular defects including epistaxis, blood vessel dilations (telangiectasia) and arteriovenous malformations (AVM) in several organs. About 90% of the cases are associated with heterozygous mutations of ACVRL1 or ENG genes, that respectively encode a bone morphogenetic protein receptor (activin receptor-like kinase 1, ALK1) and a co-receptor named endoglin. Less frequent mutations found in the remaining 10% of patients also affect the gene SMAD4 which is part of the transcriptional complex directly activated by this pathway. Presently, the therapeutic treatments for HHT are intended to reduce the symptoms of the disease. However, recent progress has been made using drugs that target VEGF (vascular endothelial growth factor) and the angiogenic pathway with the use of bevacizumab (anti-VEGF antibody). Furthermore, several exciting high-throughput screenings and preclinical studies have identified new molecular targets directly related to the signaling pathways affected in the disease. These include FKBP12, PI3-kinase and angiopoietin-2. This review aims at reporting these recent developments that should soon allow a better care of HHT patients.
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Affiliation(s)
- Florian Robert
- Univ. Grenoble Alpes, Inserm, CEA, Laboratory Biology of Cancer and Infection, F-38000, Grenoble, France
| | - Agnès Desroches-Castan
- Univ. Grenoble Alpes, Inserm, CEA, Laboratory Biology of Cancer and Infection, F-38000, Grenoble, France
| | - Sabine Bailly
- Univ. Grenoble Alpes, Inserm, CEA, Laboratory Biology of Cancer and Infection, F-38000, Grenoble, France
| | - Sophie Dupuis-Girod
- Univ. Grenoble Alpes, Inserm, CEA, Laboratory Biology of Cancer and Infection, F-38000, Grenoble, France.,Hospices Civils de Lyon, Service de Génétique, Hôpital Femme-Mère-Enfants, F-69677, Bron, France.,Centre National de Référence pour la Maladie de Rendu-Osler, F-69677, Bron, France
| | - Jean-Jacques Feige
- Univ. Grenoble Alpes, Inserm, CEA, Laboratory Biology of Cancer and Infection, F-38000, Grenoble, France.
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Abstract
Background Hereditary hemorrhagic telangiectasia is an inherited autosomal dominant disease presenting with recurrent bleeding episodes and iron deficiency anemia due to vascular malformations. Hereditary hemorrhagic telangiectasia is associated with an increased risk of stroke, gastrointestinal bleeding and pulmonary hypertension and life expectancy is significantly reduced. Excess vascular endothelial growth factor (VEGF) plays a key role in the pathophysiology of the disease. Case presentation Here we report about a male patient with hereditary hemorrhagic telangiectasia presenting with pulmonary and central nervous system involvement experiencing repetitive nosebleeds, necessitating frequent local cauterization and transfusion of more than 100 units of packed red blood cells. After initiation of temporary therapy with the anti-VEGF antibody bevacizumab at a dosage of 1 mg/kg body weight every 2 weeks, the nose bleeding episodes and the epistaxis severity score significantly decreased and long-lasting transfusion independence was achieved. Reinitiation of low-dose bevacizumab after relapse again proved effective without any documented therapy-related adverse events. In comparison to other reported anti-VEGF antibody protocols in hereditary hemorrhagic telangiectasia, our treatment approach proved to be cost-efficient. Conclusion Intermittent low-dose therapy with bevacizumab represents an effective and cost-efficient treatment option for transfusion-dependent patients with hereditary hemorrhagic telangiectasia.
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Blei F. Update December 2016. Lymphat Res Biol 2016. [DOI: 10.1089/lrb.2016.29016.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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