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Clinical Updates on Hereditary Hemorrhagic Telangiectasia (HHT) and Other Vascular Diseases

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Vascular Medicine".

Deadline for manuscript submissions: 29 August 2025 | Viewed by 2324

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Guest Editor
Department of Otorhinolaryngology, Heves County Markhot Ferenc Teaching Hospital and Outpatient Clinic, Eger, Hungary
Interests: hereditary diseases; genetics; otolaryngology

Special Issue Information

Dear Colleagues,

Hereditary hemorrhagic telangiectasia (HHT) is listed in both the capillary (telangiectasia subgroup) and the arteriovenous malformation (AVM) groups in the 2018 classification from the International Society for the Study of Vascular Anomalies (ISSVA). In 2024, thirty years after the identification of the first causative gene, endoglin (ENG), the diagnosis of HHT remains a challenge, as it is a rare disease (with a prevalence of 1:5000–1:10,000) with age-related penetrance of its multisystemic symptoms, and in addition, congenital pulmonary and cerebral AVMs are most often asymptomatic until emerging as severe, acute complications in a subset of patients. The involved disciplines might address the symptoms one by one, often without the chance to assemble the underlying syndrome. All variant types (missense, nonsense, splice-site, frameshift, in-frame deletions and insertions, and finally, large deletions and insertions in 10% of cases) have been described throughout the causative ENG, ACVRL1, and SMAD4 genes. In 2021, 510 ENG and 572 ACVRL1 variants were known.

Despite the unequivocal diagnostic criteria published in 2000 and the international guidelines for the diagnosis and management of HHT issued in 2011 and revised in 2020, the average diagnostic time lag (the interval between the first symptoms and the diagnosis of HHT) is still almost three decades for probands and only somewhat shorter for at-risk family members. Other vascular diseases resembling more or less HHT, especially the capillary malformation-arteriovenous malformation (CM-AVM) syndromes 1 and 2 (caused by RASA1 and EPHB4 mutations, respectively), are even less prevalent (approx. 1:100,000). Considering the above clinical and genetic peculiarities of the above conditions, their diagnosis and therapy is the subject of extensive research. Groups from all clinical specialties and genetic institutions are encouraged to submit their original research and review manuscripts to this Special Issue of the Journal of Clinical Medicine.

Dr. Tamás Major
Guest Editor

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Keywords

  • hereditary hemorrhagic telangiectasia (HHT)
  • arteriovenous malformations
  • embolization
  • VEGF
  • capillary malformation-arteriovenous malformation

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Published Papers (3 papers)

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16 pages, 1873 KiB  
Article
Feeding-Artery Microvascular Plug Embolization Versus Nidus-Plus-Feeding-Artery Coil Embolization of Pulmonary Arteriovenous Malformations
by Shanmukha Srinivas, Dustin G. Roberts, Justin P. McWilliams and Lucas R. Cusumano
J. Clin. Med. 2025, 14(9), 2980; https://doi.org/10.3390/jcm14092980 - 25 Apr 2025
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Abstract
Background/Objectives: Microvascular plug embolization in the distal feeding artery (FA-MVP) and coil embolization targeting the nidus and feeding artery (NiFA-coil) are effective treatments for pulmonary arteriovenous malformations (PAVMs). This study compares their outcomes. Methods: A retrospective chart review was conducted on [...] Read more.
Background/Objectives: Microvascular plug embolization in the distal feeding artery (FA-MVP) and coil embolization targeting the nidus and feeding artery (NiFA-coil) are effective treatments for pulmonary arteriovenous malformations (PAVMs). This study compares their outcomes. Methods: A retrospective chart review was conducted on patients who underwent NiFA-coil or FA-MVP embolization for PAVMs between October 2014 and May 2024, with initial (short-term) follow-up chest CT imaging performed within 18 months, and the latest (long-term) follow-up performed at least 3 years post-treatment. Durable occlusion was defined as ≥70% shrinkage of the nidus or draining vein on follow-up CT. A Cox proportional hazards regression model assessed the association between technique and durable occlusion, with inverse propensity score weighting used to adjust for patient and PAVM characteristics. Results: A total of 142 PAVMs (48 FA-MVP, 94 NiFA-coil) in 85 patients were analyzed. Durable occlusion was 97.2% (138/142) at a median short-term follow-up of 4.2 months and 90.2% (37/41) at a median long-term follow-up of 56.0 months. Simple PAVMs were more frequent in the FA-MVP group (93.8%, 45/48) than in the NiFA-coil group (61.2%, 58/94) (p < 0.001). The NiFA-coil group had larger feeding arteries (3.8 mm vs. 2.3 mm, p < 0.001) and sac sizes (13.1 mm vs. 7.7 mm, p = 0.040). Short and long-term durable occlusion rates were comparable (NiFA-coil: 96.8% and 88.9%; FA-MVP: 97.8% and 92.9%, respectively; p > 0.99, p > 0.99). After propensity score matching, compared to FA-MVP, NiFA-coil had a hazard ratio for short-term persistence of 1.06 (95% CI, 0.16–6.99; p = 0.956). Conclusions: Both NiFA-coil and FA-MVP embolization are highly effective for PAVM treatment, with similar success rates. Full article
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17 pages, 6140 KiB  
Article
Reperfusion of Pulmonary Arteriovenous Malformations Treated by Catheter Embolization
by Bianca Gulich, Arno Buecker and Guenther Schneider
J. Clin. Med. 2024, 13(24), 7812; https://doi.org/10.3390/jcm13247812 - 20 Dec 2024
Cited by 1 | Viewed by 683
Abstract
Objective: The aim of this study was to evaluate patients with hereditary hemorrhagic telangiectasia (HHT) for the potential reperfusion of pulmonary arteriovenous malformations (PAVM) treated by catheter embolization using coils or embolization plugs and to analyze causes of possible reperfusion in order to [...] Read more.
Objective: The aim of this study was to evaluate patients with hereditary hemorrhagic telangiectasia (HHT) for the potential reperfusion of pulmonary arteriovenous malformations (PAVM) treated by catheter embolization using coils or embolization plugs and to analyze causes of possible reperfusion in order to further improve treatment. Methods: This retrospective study analyzed the data of 345 patients who underwent screening for pulmonary arteriovenous malformations in cases of suspected or confirmed HHT (Osler’s disease). Of these, 118 patients with PAVM that underwent catheter embolization and had at least one follow-up study were included in our study and evaluated for potential reperfusion. Screening and follow-up for the detection of PAVM was performed by dynamic and high-resolution contrast-enhanced magnetic resonance angiography (MRA). The average follow-up time was 6.2 years. Results: Reperfusion was detected in 43 of 118 patients at follow-up. Thirty-five of these patients showed a recanalization of the treated vessel and in eleven patients the formation of collateral vessels resupplying the PAVM were identified as the cause of reperfusion. The average time between embolization and detected reperfusion was 5.6 years. The recanalization of both coils and plugs was observed. The recanalization of coils could be attributed in most cases to an insufficient packing density of the implanted coils. In addition, an enlarged diameter of the feeding artery was confirmed as a risk factor for reperfusion. Conclusions: As the reperfusion of embolized pulmonary arteriovenous malformations can occur after a long time interval post-treatment, regular lifelong follow-up studies after embolization are essential to detect reperfusion at an early stage and avoid serious complications like a brain abscess or stroke through prompt re-embolization. After coil embolization, attention should be paid to sufficiently dense packing to achieve adequate and permanent occlusion. Full article
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5 pages, 8414 KiB  
Case Report
Spontaneous Ischemic Cholecystitis in a Patient with Hereditary Hemorrhagic Telangiectasia (HHT)
by Romain L’Huillier, Alexandre Garnaud and Olivier Monneuse
J. Clin. Med. 2024, 13(22), 6653; https://doi.org/10.3390/jcm13226653 - 6 Nov 2024
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Abstract
Background/Objectives: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by abnormal blood vessel formation, leading to recurrent epistaxis, cutaneous and mucosal telangiectases, and visceral arteriovenous malformations (AVMs). Hepatic involvement may result in complications such as high-output heart failure, portal hypertension, and [...] Read more.
Background/Objectives: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by abnormal blood vessel formation, leading to recurrent epistaxis, cutaneous and mucosal telangiectases, and visceral arteriovenous malformations (AVMs). Hepatic involvement may result in complications such as high-output heart failure, portal hypertension, and biliary ischemia. We report an uncommon case of ischemic cholecystitis in a patient with HHT. Methods: A 57-year-old male with HHT type 1, including gastric telangiectases and hepatic AVMs, presented with anemia, melena, epigastric pain, and a history of recurrent epistaxis. Imaging revealed gastric telangiectases and liver AVMs, consistent with HHT. Following an episode of severe epistaxis and aspiration pneumonia, the patient developed right upper quadrant pain. Results: Abdominal CT and ultrasound identified thickening of the gallbladder wall, segmental enhancement defects, and a perivesicular fluid effusion, suggestive of acalculous cholecystitis. A laparoscopic cholecystectomy was performed, revealing ischemic cholecystitis with necrotic gallbladder walls. Conclusions: This case underscores the potential for ischemic cholecystitis in patients with HHT and liver involvement, particularly under conditions of acute hemodynamic instability. Clinicians should be vigilant in recognizing this rare complication, especially in patients with established HHT and associated hepatic vascular anomalies. Full article
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