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.
References
Shovlin CL, Hughes JM, Tuddenham EG, Temperley I, Perembelon YF, Scott J, Seidman CE, Seidman JG (1994) A gene for hereditary haemorrhagic telangiectasia maps to chromosome 9q3. Nat Genet 6:205–209
Johnson DW, Berg JN, Baldwin MA, Gallione CJ, Marondel I, Yoon SJ, Stenzel TT, Speer M et al (1996) Mutations in the activin receptor-like kinase 1 gene in hereditary haemorrhagic telangiectasia type 2. Nat Genet 13:189–195
Gallione CJ, Repetto GM, Legius E, Rustgi AK, Schelley SL, Tejpar S, Mitchell G, Drouin E et al (2004) A combined syndrome of juvenile polyposis and hereditary haemorrhagic telangiectasia associated with mutations in MADH4 (SMAD4). Lancet 363:852–859
McDonald J, Damjanovich K, Millson A, Wooderchak W, Chibuk JM, Stevenson DA, Gedge F, Bayrak-Toydemir P (2011) Molecular diagnosis in hereditary hemorrhagic telangiectasia: findings in a series tested simultaneously by sequencing and deletion/duplication analysis. Clin Genet 79:335–344
McDonald J, Wooderchak-Donahue W, VanSant Webb C, Whitehead K, Stevenson DA, Bayrak-Toydemir P (2015) Hereditary hemorrhagic telangiectasia: genetics and molecular diagnostics in a new era. Front Genet 6(1):1–8. doi:10.3389/fgene.2015.00001
Bushby K, Finkel R, Wong B, Barohn R, Campbell C, Comi GP, Connolly AM, Day JW et al (2014) Ataluren treatment of patients with nonsense mutation dystrophinopathy. Muscle Nerve 50(4):477–487
Kerem E, Konstan MW, De Boeck K, Accurso FJ, Sermet-Gaudelus I, Wilschanski M, Elborn JS et al (2014) Ataluren for the treatment of nonsense-mutation cystic fibrosis: a randomised, double-blind, placebo-controlled phase 3 trial. Lancet Respir Med 2(7):539–547
Wooderchak-Donahue W, McDonald J, O’Fallon B, Upton PD, Li W, Roman BL, Young S, Plant P et al (2013) BMP9 mutations cause a vascular anomaly syndrome with phenotypic overlap with hereditary hemorrhagic telangiectasia. Am J Hum Genet 93:1–8
Rigelsky CM, Jennings C, Lehtonen R, Minai OA, Eng C, Aldred MA (2008) BMPR2 mutation in a patient with pulmonary arterial hypertension and suspected hereditary hemorrhagic telangiectasia. Am J Med Genet A 146A(19):2551–2556
Larrivée B, Prahst C, Gordon E, del Toro R, Mathivet T, Duarte A, Simons M, Eichmann A (2012) ALK1 signaling inhibits angiogenesis by cooperating with the Notch pathway. Dev Cell 22(3):489–500
Cartin-Ceba R, Swanson KL, Krowka MJ (2013) Pulmonary arteriovenous malformations. Chest 144:1033–1044
Kjeldsen AD, Oxhoj H, Andersen PE, Green A, Vase P (2000) Prevalence of pulmonary arteriovenous malformations (PAVM) and occurrence of neurological symptoms in patients with hereditary haemorrhagic telangiectasia (HHT). J Intern Med 248:255–262
Moussouttas M, Fayad P, Rosenblatt M, Hashimoto M, Pollak J, Henderson K, Ma TY, White RI (2000) Pulmonary arteriovenous malformations: cerebral ischemia and neurologic manifestations. Neurology 55:959–964
Shovlin CL, Jackson JE, Bamford KB, Jenkins IH, Benjamin AR, Ramadan H, Kulinskaya E (2008) Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia. Thorax 63:259–266
Velthuis S, Buscarini E, van Gent MW, Gazzaniga P, Manfredi G, Danesino C, Schonewille WJ, Westermann CJ et al (2013) Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications: a striking association. Chest 144:542–548
Faughnan ME, Palda VA, Garcia-Tsao G, Geisthoff UW, McDonald J, Proctor DD, Spears J, Brown DH et al (2011) International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet 48:73–87
Velthuis S, Buscarini E, Gossage JR, Snijder RJ, Mager JJ, Post MC (2015) Clinical implications of pulmonary shunting on saline contrast echocardiography. J Am Soc Echocardiogr 28:255–263
Elliott JE, Nigam SM, Laurie SS, Beasley KM, Goodman RD, Hawn JA, Gladstone IM, Chesnutt MS, Lovering AT (2013) Prevalence of left heart contrast in healthy, young, asymptomatic humans at rest breathing room air. Respir Physiol Neurobiol 188:71–78
Lovering AT, Stickland MK, Amann M, Murphy JC, O’Brien MJ, Hokanson JS, Eldridge MW (2008) Hyperoxia prevents exercise-induced intrapulmonary arteriovenous shunt in healthy humans. J Physiol 586(18):4559–4565
Li W, Niu B, Henderson K, Northrup V, Pollak JS, Trow T, Fahey J, White RI Jr (2011) Reproducibility of oxygen saturation monitoring during six-minute walk test and exercise stress test in patients with pulmonary arteriovenous malformations associated with hereditary hemorrhagic telangiectasia. Pediatr Cardiol 32:590–594
Faughnan ME, Thabet A, Mei-Zahav M, Colombo M, Maclusky I, Hyland RH, Pugash RA, Chait P, Henderson KJ, White RI (2004) Pulmonary arteriovenous malformations in children: outcomes of transcatheter embolotherapy. J Pediatr 145:826–831
Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, Beghetti M, Corris P et al (2009) Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 30:2493–2537
Arthur HM, Ure J, Smith AJ, Renforth G, Wilson DI, Torsney E, Charlton R, Parums DV et al (2000) Endoglin, an ancillary TGFbeta receptor, is required for extraembryonic angiogenesis and plays a key role in heart development. Dev Biol 217:42–53
Bourdeau A, Dumont DJ, Letarte M (1999) A murine model of hereditary hemorrhagic telangiectasia. J Clin Invest 104:1343–1351
Mahmoud M, Allinson KR, Zhai Z, Oakenfull R, Ghandi P, Adams RH, Fruttiger M, Arthur HM (2010) Pathogenesis of arteriovenous malformations in the absence of endoglin. Circ Res 106:1425–1433
Oh SP, Seki T, Goss KA, Imamura T, Yi Y, Donahoe PK, Li L, Miyazono K et al (2000) Activin receptor-like kinase 1 modulates transforming growth factor-b1 signaling in the regulation of angiogenesis. Proc Natl Acad Sci USA 97:2626–2631
Park SO, Lee YJ, Seki T, Hong KH, Fliess N, Jiang Z, Park A, Wu X et al (2008) ALK5- and TGFBR2-independent role of ALK1 in the pathogenesis of hereditary hemorrhagic telangiectasia type 2. Blood 111:633–642
Park SO, Wankhede M, Lee YJ, Choi EJ, Fliess N, Choe SW, Oh SH, Walter G et al (2009) Real-time imaging of de novo arteriovenous malformation in a mouse model of hereditary hemorrhagic telangiectasia. J Clin Invest 119:3487–3496
Roman BL, Pham VN, Lawson ND, Kulik M, Childs S, Lekven AC, Garrity DM, Moon RT et al (2002) Disruption of acvrl1 increases endothelial cell number in zebrafish cranial vessels. Development 129:3009–3019
Srinivasan S, Hanes MA, Dickens T, Porteous ME, Oh SP, Hale LP, Marchuk DA (2003) A mouse model for hereditary hemorrhagic telangiectasia (HHT) type 2. Hum Mol Genet 12:473–482
Urness LD, Sorensen LK, Li DY (2000) Arteriovenous malformations in mice lacking activin receptor-like kinase-1. Nat Genet 26:328–331
Bourdeau A, Cymerman U, Paquet ME, Meschino W, McKinnon WC, Guttmacher AE, Becker L, Letarte M (2000) Endoglin expression is reduced in normal vessels but still detectable in arteriovenous malformations of patients with hereditary hemorrhagic telangiectasia type 1. Am J Pathol 156:911–923
Hawinkels LJ, Kuiper P, Wiercinska E, Verspaget HW, Liu Z, Pardali E, Sier CF, ten Dijke P (2010) Matrix metalloproteinase-14 (MT1–MMP)-mediated endoglin shedding inhibits tumor angiogenesis. Cancer Res 70:4141–4150
Valbuena-Diez AC, Blanco FJ, Oujo B, Langa C, Gonzalez-Nunez M, Llano E, Pendas AM, Diaz M et al (2012) Oxysterol-induced soluble endoglin release and its involvement in hypertension. Circulation 126:2612–2624
Mallet C, Lamribet K, Giraud S, Dupuis-Girod S, Feige JJ, Bailly S, Tillet E (2014) Functional analysis of endoglin mutations from hereditary hemorrhagic telangiectasia type 1 patients reveals different mechanisms for endoglin loss of function. Hum Mol Genet 24(4):1142–1154
Corti P, Young S, Chen CY, Patrick MJ, Rochon ER, Pekkan K, Roman BL (2011) Interaction between alk1 and blood flow in the development of arteriovenous malformations. Development 138:1573–1582
Choi EJ, Walker EJ, Shen F, Oh SP, Arthur HM, Young WL, Su H (2012) Minimal homozygous endothelial deletion of Eng with VEGF stimulation is sufficient to cause cerebrovascular dysplasia in the adult mouse. Cerebrovasc Dis 33:540–547
Garrido-Martin EM, Nguyen HL, Cunningham TA, Choe SW, Jiang Z, Arthur HM, Lee YJ, Oh SP (2014) Common and distinctive pathogenetic features of arteriovenous malformations in hereditary hemorrhagic telangiectasia 1 and hereditary hemorrhagic telangiectasia 2 animal models—brief report. Arterioscler Thromb Vasc Biol 34:2232–2236
Han C, Choe SW, Kim YH, Acharya AP, Keselowsky BG, Sorg BS, Lee YJ, Oh SP (2014) VEGF neutralization can prevent and normalize arteriovenous malformations in an animal model for hereditary hemorrhagic telangiectasia 2. Angiogenesis 17:823–830
Hao Q, Zhu Y, Su H, Shen F, Yang GY, Kim H, Young WL (2010) VEGF induces more severe cerebrovascular dysplasia in endoglin than in alk1 mice. Transl Stroke Res 1:197–201
Walker EJ, Su H, Shen F, Choi EJ, Oh SP, Chen G, Lawton MT, Kim H et al (2011) Arteriovenous malformation in the adult mouse brain resembling the human disease. Ann Neurol 69:954–962
Bayrak-Toydemir P, McDonald J, Markewitz B, Lewin S, Miller F, Chou LS, Gedge F, Tang W et al (2006) Genotype–phenotype correlation in hereditary hemorrhagic telangiectasia: mutations and manifestations. Am J Med Genet A 140(5):463–470
Berg J, Porteous M, Reinhardt D, Gallione C, Holloway S, Umasunthar T, Lux A, McKinnon W et al (2003) Hereditary haemorrhagic telangiectasia: a questionnaire based study to delineate the different phenotypes caused by endoglin and ALK1 mutations. J Med Genet 40(8):585–590
Kjeldsen AD, Møller TR, Brusgaard K, Vase P, Andersen PE (2005) Clinical symptoms according to genotype amongst patients with hereditary haemorrhagic telangiectasia. J Intern Med 258(4):349–355
Letteboer TG, Mager HJ, Snijder RJ, Lindhout D, Ploos van Amstel HK, Zanen P, Westermann KJ (2008) Genotype–phenotype relationship for localization and age distribution of telangiectases in hereditary hemorrhagic telangiectasia. Am J Med Genet A 146A(21):2733–2739
Letteboer TG, Mager JJ, Snijder RJ, Koeleman BP, Lindhout D, Ploos van Amstel JK, Westermann CJ (2006) Genotype–phenotype relationship in hereditary haemorrhagic telangiectasia. J Med Genet 43(4):371–377
Shovlin CL (2010) Hereditary haemorrhagic telangiectasia: pathophysiology, diagnosis and treatment. Blood Rev 24(6):203–219
Wever-Pinzon O, Selzman CH, Drakos SG, Saidi A, Stoddard GJ, Gilbert EM, Labedi M, Reid BB et al (2013) Pulsatility and the risk of nonsurgical bleeding in patients supported with the continuous-flow left ventricular assist device HeartMate II. Circ Heart Fail 6(3):517–526
Tual-Chalot S, Mahmoud M, Allinson KR, Redgrave RE, Zhai Z, Oh SP, Fruttiger M, Arthur HM (2014) Endothelial depletion of Acvrl1 in mice leads to arteriovenous malformations associated with reduced endoglin expression. PLoS ONE 9(6):e98646
Yoshimatsu Y, Lee YG, Akatsu Y, Taguchi L, Suzuki HI, Cunha SI, Maruyama K, Suzuki Y (2013) Bone morphogenetic protein-9 inhibits lymphatic vessel formation via activin receptor-like kinase 1 during development and cancer progression. Proc Natl Acad Sci USA 110(47):18940–18945
Gaillard S, Dupuis-Girod S, Boutitie F, Riviere S, Moriniere S, Hatron PY, Manfredi G, Kaminsky P et al (2014) Tranexamic acid for epistaxis in hereditary hemorrhagic telangiectasia patients: a European cross-over controlled trial in a rare disease. J Thromb Haemost 12:1494–1502
Geisthoff UW, Seyfert UT, Kubler M, Bieg B, Plinkert PK, Konig J (2014) Treatment of epistaxis in hereditary hemorrhagic telangiectasia with tranexamic acid—a double-blind placebo-controlled cross-over phase IIIB study. Thromb Res 134:565–571
Cirulli A, Liso A, D’Ovidio F, Mestice A, Pasculli G, Gallitelli M, Rizzi R, Specchia G, Sabba C (2003) Vascular endothelial growth factor serum levels are elevated in patients with hereditary hemorrhagic telangiectasia. Acta Haematol 110:29–32
Dupuis-Girod S, Ginon I, Saurin JC, Marion D, Guillot E, Decullier E, Roux A, Carette MF et al (2012) Bevacizumab in patients with hereditary hemorrhagic telangiectasia and severe hepatic vascular malformations and high cardiac output. JAMA 307:948–955
Thompson AB, Ross DA, Berard P, Figueroa-Bodine J, Livada N, Richer SL (2014) Very low dose bevacizumab for the treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia. Allergy Rhinol 5:e91–e95. doi:10.2500/ar.2014.5.0091
Riss D, Burian M, Wolf A, Kranebitter V, Kaider A, Arnoldner C (2015) Intranasal submucosal bevacizumab for epistaxis in hereditary hemorrhagic telangiectasia: a double-blind, randomized, placebo-controlled trial. Head Neck 37(6):783–787
Dupuis-Girod S, Ambrun A, Decullier E, Samson G, Roux A, Fargeton AE, Rioufol C, Schwiertz V et al (2014) ELLIPSE Study: a Phase 1 study evaluating the tolerance of bevacizumab nasal spray in the treatment of epistaxis in hereditary hemorrhagic telangiectasia. MAbs 6:794–799
Lebrin F, Srun S, Raymond K, Martin S, van den Brink S, Freitas C, Breant C, Mathivet T et al (2010) Thalidomide stimulates vessel maturation and reduces epistaxis in individuals with hereditary hemorrhagic telangiectasia. Nat Med 16:420–428
Jameson JJ, Cave DR (2004) Hormonal and antihormonal therapy for epistaxis in hereditary hemorrhagic telangiectasia. Laryngoscope 114:705–709
Van Cutsem E, Rutgeerts P, Vantrappen G (1990) Treatment of bleeding gastrointestinal vascular malformations with oestrogen-progesterone. Lancet 335:953–955
Vase P (1981) Estrogen treatment of hereditary hemorrhagic telangiectasia. A double-blind controlled clinical trial. Acta Med Scand 209:393–396
Bergler W, Sadick H, Gotte K, Riedel F, Hormann K (2002) Topical estrogens combined with argon plasma coagulation in the management of epistaxis in hereditary hemorrhagic telangiectasia. Ann Otol Rhinol Laryngol 111:222–228
Yaniv E, Preis M, Hadar T, Shvero J, Haddad M (2009) Antiestrogen therapy for hereditary hemorrhagic telangiectasia: a double-blind placebo-controlled clinical trial. Laryngoscope 119:284–288
AlbinanaV Bernabeu-Herrero ME, Zarrabeitia R, Bernabeu C, Botella LM (2010) Estrogen therapy for hereditary haemorrhagic telangiectasia (HHT): effects of raloxifene, on endoglin and ALK1 expression in endothelial cells. Thromb Haemost 103:525–534
Bjelakovic B, Bojanovic M, Lukic S, Saranac L, Vukomanovic V, Prijic S, Zivkovic N, Randjelovic D (2013) The therapeutic efficacy of propranolol in children with recurrent primary epistaxis. Drug Des Devel Ther 7:127–129
de Gussem EM, Snijder RJ, Disch FJ, Zanen P, Westermann CJ, Mager JJ (2009) The effect of N-acetylcysteine on epistaxis and quality of life in patients with HHT: a pilot study. Rhinology 47:85–88
Reh DD, Hur K, Merlo CA (2013) Efficacy of a topical sesame/rose geranium oil compound in patients with hereditary hemorrhagic telangiectasia associated epistaxis. Laryngoscope 123:820–822
Faughnan ME, Lui YW, Wirth JA, Pugash RA, Redelmeier DA, Hyland RH, White RI (2000) Diffuse pulmonary arteriovenous malformations: characteristics and prognosis. Chest 117:31–38
Lacombe P, Lacout A, Marcy PY, Binsse S, Sellier J, Bensalah M, Chinet T, Bourgault-Villada I et al (2013) Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: an overview. Diagn Interv Imaging 94:835–848
Lacombe P, Lagrange C, El Hajjam M, Chinet T, Pelage JP (2005) Reperfusion of complex pulmonary arteriovenous malformations after embolization: report of three cases. Cardiovasc Intervent Radiol 28:30–35
Milic A, Chan RP, Cohen JH, Faughnan ME (2005) Reperfusion of pulmonary arteriovenous malformations after embolotherapy. J Vasc Interv Radiol 16:1675–1683
Pollak JS, Saluja S, Thabet A, Henderson KJ, Denbow N, White RI (2006) Clinical and anatomic outcomes after embolotherapy of pulmonary arteriovenous malformations. J Vasc Interv Radiol 17:35–45
Brillet PY, Dumont P, Bouaziz N, Duhamel A, Laurent F, Remy J, Remy-Jardin M (2007) Pulmonary arteriovenous malformation treated with embolotherapy: systemic collateral supply at multidetector CT angiography after 2–20-year follow-up. Radiology 242:267–276
Acknowledgments
We would like to acknowledge the financial support of Cure HHT and the scientific contributions of the attendees that made this meeting possible.
Funding
This conference was supported by Cure HHT, HHT Ireland, Covidien, Medtronic, ARUP Laboratories, Genetic Diagnostic Laboratory, Boston Scientific, Actelion, Ambry Genetics, Gilead, B. Braun GeGaT, and St. Jude Medical.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
J. Gossage is a part time paid Medical Director of Cure HHT; C. Hughes was reimbursed for meeting expenses by Cure HHT; the other authors report no conflicts.
Rights and permissions
About this article
Cite this article
Arthur, H., Geisthoff, U., Gossage, J.R. et al. Executive summary of the 11th HHT international scientific conference. Angiogenesis 18, 511–524 (2015). https://doi.org/10.1007/s10456-015-9482-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10456-015-9482-5