Hepatic Vascular Malformations in Hereditary Hemorrhagic Telangiectasia

 

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ABSTRACT

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular disorder that can involve the liver diffusely in the form of vascular malformations ranging from small telangiectases to discrete arteriovenous malformations. Anatomically, three different patterns of abnormal vascular communications can occur in liver: portal vein to hepatic vein (portovenous), hepatic artery to hepatic vein (arteriovenous) and hepatic artery to portal vein (arterioportal), with the most common being arteriovenous. Only 5 to 8% of patients with these vascular malformations are symptomatic. When symptomatic, patients present with high-output cardiac failure, biliary ischemia (which, when severe, can progress to biliary and hepatic necrosis and lead to acute liver failure), or portal hypertension. Other less common presentations include portosystemic encephalopathy and abdominal angina. Diagnosis is confirmed by Doppler ultrasonography or multidetector computed tomography. The hallmark findings are intrahepatic hypervascularization and an enlarged common hepatic artery. Focal nodular hyperplasia and nodular regenerative hyperplasia are common findings. Symptomatic patients are treated with intensive medical treatment aimed at the predominant clinical presentation. Patients who fail aggressive medical therapy and those with acute biliary/hepatic necrosis should be considered for liver transplantation.

REFERENCES

• 1 Plauchu H, DeChadarevian J P, Bideau A et al.. Age-related clinical profile of hereditary hemorrhagic telangiectasia in an epidemiologically recruited population.  Am J Med Genet. 1989;  32 291-297
  CrossrefPubMedGoogle Scholar
• 2 Dakeishi M, Shioya T, Wada Y et al.. Genetic epidemiology of hereditary hemorrhagic telangiectasia in a local community in the northern part of Japan.  Hum Mutat. 2002;  19 140-148
  CrossrefPubMedGoogle Scholar
• 3 Kjeldsen A D, Vase P, Green A. Hereditary haemorrhagic telangiectasia: a population-based study of prevalence and mortality in Danish patients.  J Intern Med. 1999;  245 31-39
  CrossrefPubMedGoogle Scholar
• 4 Braverman I M, Keh A, Jacobson B S. Ultrastructure and three-dimensional organization of the telangiectases of hereditary hemorrhagic telangiectasia.  J Invest Dermatol. 1990;  95 422-427
  CrossrefPubMedGoogle Scholar
• 5 Guttmacher A E, Marchuk D A, White R I. Hereditary hemorrhagic telangiectasia.  N Engl J Med. 1995;  333 918-924
  CrossrefPubMedGoogle Scholar
• 6 Shovlin C L, Guttmacher A E, Buscarini E et al.. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome).  Am J Med Genet. 2000;  91 66-67
  CrossrefPubMedGoogle Scholar
• 7 McAllister K A, Grogg K M, Johnson D W et al.. Endoglin, a TGF-beta binding protein of endothelial cells, is the gene for hereditary haemorrhagic telangiectasia type 1.  Nat Genet. 1994;  8 345-351
  CrossrefPubMedGoogle Scholar
• 8 Johnson D W, Berg J N, Baldwin M A et al.. Mutations in the activin receptor-like kinase 1 gene in hereditary haemorrhagic telangiectasia type 2.  Nat Genet. 1996;  13 189-195
  CrossrefPubMedGoogle Scholar
• 9 McDonald M T, Papenberg K A, Ghosh S et al.. A disease locus for hereditary haemorrhagic telangiectasia maps to chromosome 9q33–34.  Nat Genet. 1994;  6 197-204
  PubMedGoogle Scholar
• 10 Shovlin C L, Hughes J M, Tuddenham E G et al.. A gene for hereditary haemorrhagic telangiectasia maps to chromosome 9q3.  Nat Genet. 1994;  6 205-209
  PubMedGoogle Scholar
• 11 Johnson D W, Berg J N, Gallione C J et al.. A second locus for hereditary hemorrhagic telangiectasia maps to chromosome 12.  Genome Res. 1995;  5 21-28
  CrossrefPubMedGoogle Scholar
• 12 Vincent P, Plauchu H, Hazan J et al.. A third locus for hereditary haemorrhagic telangiectasia maps to chromosome 12q.  Hum Mol Genet. 1995;  4 945-949
  CrossrefPubMedGoogle Scholar
• 13 Cole S G, Begbie M E, Wallace G M et al.. A new locus for hereditary haemorrhagic telangiectasia (HHT3) maps to chromosome 5.  J Med Genet. 2005;  42 577-582
  CrossrefPubMedGoogle Scholar
• 14 Bayrak-Toydemir P, McDonald J, Akarsu N et al.. A fourth locus for hereditary hemorrhagic telangiectasia maps to chromosome 7.  Am J Med Genet A. 2006;  140 2155-2162
  PubMedGoogle Scholar
• 15 Gallione C J, Repetto G M, Legius E et al.. A combined syndrome of juvenile polyposis and hereditary haemorrhagic telangiectasia associated with mutations in MADH4 (SMAD4).  Lancet. 2004;  363 852-859
  CrossrefPubMedGoogle Scholar
• 16 Berg J, Porteous M, Reinhardt D et al.. Hereditary haemorrhagic telangiectasia: a questionnaire based study to delineate the different phenotypes caused by endoglin and ALK1 mutations.  J Med Genet. 2003;  40 585-590
  CrossrefPubMedGoogle Scholar
• 17 Bayrak-Toydemir P, McDonald J, Markewitz B et al.. Genotype-phenotype correlation in hereditary hemorrhagic telangiectasia: mutations and manifestations.  Am J Med Genet A. 2006;  140 463-470
  PubMedGoogle Scholar
• 18 Lesca G, Olivieri C, Burnichon N et al.. Genotype-phenotype correlations in hereditary hemorrhagic telangiectasia: data from the French-Italian HHT network.  Genet Med. 2007;  9 14-22
  CrossrefPubMedGoogle Scholar
• 19 Letteboer T G, Mager H J, Snijder R J et al.. Genotype-phenotype relationship in hereditary hemorrhagic telangiectasia.  J Med Genet. 2006;  43 371-377
  PubMedGoogle Scholar
• 20 Sabba C, Pasculli G, Lenato G M et al.. Hereditary hemorrhagic telangiectasia: clinical features in ENG and ALK1 mutation carriers.  J Thromb Haemost. 2007;  5 1149-1157
  CrossrefPubMedGoogle Scholar
• 21 Cloft H J. Spontaneous regression of cerebral arteriovenous malformation in hereditary hemorrhagic telangiectasia.  AJNR Am J Neuroradiol. 2002;  23 1049-1050
  PubMedGoogle Scholar
• 22 Leung K M, Agid R, terBrugge K. Spontaneous regression of a cerebral arteriovenous malformation in a child with hereditary hemorrhagic telangiectasia. Case report.  J Neurosurg. 2006;  105 428-431
  PubMedGoogle Scholar
• 23 Du R, Hashimoto T, Tihan T et al.. Growth and regression of arteriovenous malformations in a patient with hereditary hemorrhagic telangiectasia. Case report.  J Neurosurg. 2007;  106 470-477
  CrossrefPubMedGoogle Scholar
• 24 Hashimoto M, Tate E, Nishii T et al.. Angiography of hepatic vascular malformations associated with hereditary hemorrhagic telangiectasia.  Cardiovasc Intervent Radiol. 2003;  26 177-180
  Google Scholar
• 25 Wheatley-Price P, Shovlin C, Chao D. Interferon for metastatic renal cell cancer causing regression of hereditary hemorrhagic telangiectasia.  J Clin Gastroenterol. 2005;  39 344-345
  PubMedGoogle Scholar
• 26 Massoud O I, Youssef W I, Mullen K D. Resolution of hereditary hemorrhagic telangiectasia and anemia with prolonged alpha-interferon therapy for chronic hepatitis C.  J Clin Gastroenterol. 2004;  38 377-379
  CrossrefPubMedGoogle Scholar
• 27 Flieger D, Hainke S, Fischbach W. Dramatic improvement in hereditary hemorrhagic telangiectasia after treatment with the vascular endothelial growth factor (VEGF) antagonist bevacizumab.  Ann Hematol. 2006;  85 631-632
  CrossrefPubMedGoogle Scholar
• 28 Mitchell A, Adams L A, MacQuillan G et al.. Bevacizumab reverses need for liver transplantation in hereditary hemorrhagic telangiectasia.  Liver Transpl. 2008;  14 210-213
  CrossrefPubMedGoogle Scholar
• 29 Wanless I R, Gryfe A. Nodular transformation of the liver in hereditary hemorrhagic telangiectasia.  Arch Pathol Lab Med. 1986;  110 331-335
  PubMedGoogle Scholar
• 30 Sawabe M, Arai T, Esaki Y et al.. Three-dimensional organization of the hepatic microvasculature in hereditary hemorrhagic telangiectasia.  Arch Pathol Lab Med. 2001;  125 1219-1223
  PubMedGoogle Scholar
• 31 Siddiki H, Doherty M G, Fletcher J G et al.. Abdominal findings in hereditary hemorrhagic telangiectasia: pictorial essay on 2D and 3D findings with isotropic multiphase CT.  Radiographics. 2008;  28 171-184
  CrossrefPubMedGoogle Scholar
• 32 Buscarini E, Danesino C, Olivieri C et al.. Doppler ultrasonographic grading of hepatic vascular malformations in hereditary hemorrhagic telangiectasia–results of extensive screening.  Ultraschall Med. 2004;  25 348-355
  Article in Thieme ConnectPubMedGoogle Scholar
• 33 Ianora A A, Memeo M, Sabba C et al.. Hereditary hemorrhagic telangiectasia: multi-detector row helical CT assessment of hepatic involvement.  Radiology. 2004;  230 250-259
  PubMedGoogle Scholar
• 34 Memeo M, Stabile Ianora A A, Scardapane A et al.. Hepatic involvement in hereditary hemorrhagic telangiectasia: CT findings.  Abdom Imaging. 2004;  29 211-220
  CrossrefPubMedGoogle Scholar
• 35 Buonamico P, Suppressa P, Lenato G M et al.. Liver involvement in a large cohort of patients with hereditary hemorrhagic telangiectasia: Echo-color-Doppler vs multislice computed tomography study.  J Hepatol. 2008;  48(5) 811-820
  CrossrefPubMedGoogle Scholar
• 36 Garcia-Tsao G, Korzenik J R, Young L et al.. Liver disease in patients with hereditary hemorrhagic telangiectasia.  N Engl J Med. 2000;  343 931-936
  CrossrefPubMedGoogle Scholar
• 37 Caselitz M, Bahr M J, Bleck J S et al.. Sonographic criteria for the diagnosis of hepatic involvement in hereditary hemorrhagic telangiectasia (HHT).  Hepatology. 2003;  37 1139-1146
  CrossrefPubMedGoogle Scholar
• 38 Ravard G, Soyer P, Boudiaf M et al.. Hepatic involvement in hereditary hemorrhagic telangiectasia: helical computed tomography features in 24 consecutive patients.  J Comput Assist Tomogr. 2004;  28 488-495
  CrossrefPubMedGoogle Scholar
• 39 Wu J S, Saluja S, Garcia-Tsao G et al.. Liver involvement in hereditary hemorrhagic telangiectasia: CT and clinical findings do not correlate in symptomatic patients.  AJR Am J Roentgenol. 2006;  187 W399–405
  PubMedGoogle Scholar
• 40 Milot L, Gautier G, Beuf O et al.. Hereditary hemorrhagic telangiectases: magnetic resonance imaging features in liver involvement.  J Comput Assist Tomogr. 2006;  30 405-411
  CrossrefPubMedGoogle Scholar
• 41 Buscarini E, Gebel M, Ocran K et al.. Interobserver agreement in diagnosing liver involvement in hereditary hemorrhagic telangiectasia by Doppler ultrasound.  Ultrasound Med Biol. 2008;  34(5) 718-725
  CrossrefPubMedGoogle Scholar
• 42 Buscarini E, Plauchu H, Garcia-Tsao G et al.. Liver involvement in hereditary hemorrhagic telangiectasia: consensus recommendations.  Liver Int. 2006;  26 1040-1046
  CrossrefPubMedGoogle Scholar
• 43 Buscarini E, Danesino C, Plauchu H et al.. High prevalence of hepatic focal nodular hyperplasia in subjects with hereditary hemorrhagic telangiectasia.  Ultrasound Med Biol. 2004;  30 1089-1097
  CrossrefPubMedGoogle Scholar
• 44 Wanless I R, Mawdsley C, Adams R. On the pathogenesis of focal nodular hyperplasia of the liver.  Hepatology. 1985;  5 1194-1200
  CrossrefPubMedGoogle Scholar
• 45 Bioulac-Sage P, Laumonier H, Cubel G et al.. Over-expression of glutamine synthase in focal nodular hyperplasia (part 1): early stages in the formation support the hypothesis of a focal hyper-arterialisation with venous (portal and hepatic) and biliary damage.  Comp Hepatol. 2008;  7 2
  CrossrefPubMedGoogle Scholar
• 46 Martini G A. The liver in hereditary haemorrhagic teleangiectasia: an inborn error of vascular structure with multiple manifestations: a reappraisal.  Gut. 1978;  19 531-537
  CrossrefPubMedGoogle Scholar
• 47 Cooney T, Sweeney E C, Coll R et al.. “Pseudocirrhosis” in hereditary hemorrhagic telangiectasia.  J Clin Pathol. 1977;  30 1134-1141
  CrossrefPubMedGoogle Scholar
• 48 Buscarini E, Buscarini L, Danesino C et al.. Hepatic vascular malformations in hereditary hemorrhagic telangiectasia: Doppler sonographic screening in a large family.  J Hepatol. 1997;  26 111-118
  CrossrefPubMedGoogle Scholar
• 49 Garcia-Tsao G. Liver involvement in hereditary hemorrhagic telangiectasia (HHT).  J Hepatol. 2007;  46 499-507
  CrossrefPubMedGoogle Scholar
• 50 Livneh A, Langevitz P, Morag B et al.. Functionally reversible hepatic arteriovenous fistulas during pregnancy in patients with hereditary hemorrhagic telangiectasia.  South Med J. 1988;  81 1047-1049
  CrossrefPubMedGoogle Scholar
• 51 Khalid S K, Perschbacher J, Makan M, Barzilai B, Goodenberger D. Increased nose bleeding heralds high output cardiac failure in hereditary hemorrhagic telangiectasia – results of a case control study.  Hematology Meeting Reports. 2007;  1 23 , (abstract)
  PubMedGoogle Scholar
• 52 Khalid S K, Perschbacher J, Makan M, Goodenberger D, Barzilai B. Quantitative echocardiographic features of high output cardiac failure associated with hereditary hemorrhagic telangiectasia (HHT): A retrospective analysis.  J Am Soc Echocardiogr. 2007;  20 625A , (abstract)
  PubMedGoogle Scholar
• 53 Trembath R C, Thomson J R, Machado R D et al.. Clinical and molecular genetic features of pulmonary hypertension in patients with hereditary hemorrhagic telangiectasia.  N Engl J Med. 2001;  345 325-334
  CrossrefPubMedGoogle Scholar
• 54 Gothlin J H, Nordgard K, Janssen K et al.. Hepatic telangiectasia in Osler's disease treated with arterial embolization.  Eur J Radiol. 1982;  2 27-30
  PubMedGoogle Scholar
• 55 Brohee D, Franken P, Fievez M et al.. High-output right ventricular failure secondary to hepatic arteriovenous microfistulae. Selective arterial embolization treatment.  Arch Intern Med. 1984;  144 1282-1284
  CrossrefPubMedGoogle Scholar
• 56 Derauf B J, Hunter D W, Sirr S A et al.. Peripheral embolization of diffuse hepatic arteriovenous malformations in a patient with hereditary hemorrhagic telangiectasia.  Cardiovasc Intervent Radiol. 1987;  10 80-83
  CrossrefPubMedGoogle Scholar
• 57 Nikolopoulos N, Xynos E, Vassilakis J S. Familial occurrence of hyperdynamic circulation status due to intrahepatic fistulae in hereditary hemorrhagic telangiectasia.  Hepatogastroenterology. 1988;  35 167-168
  PubMedGoogle Scholar
• 58 Bourgeois N, Delcour C, Deviere J et al.. Osler-Weber-Rendu disease associated with hepatic involvement and high output heart failure.  J Clin Gastroenterol. 1990;  12 236-237
  PubMedGoogle Scholar
• 59 Whiting J H, Morton K A, Datz F L et al.. Embolization of hepatic arteriovenous malformations using radiolabeled and nonradiolabeled polyvinyl alcohol sponge in a patient with hereditary hemorrhagic telangiectasia: case report.  J Nucl Med. 1992;  33 260-262
  PubMedGoogle Scholar
• 60 Caselitz M, Wagner S, Chavan A et al.. Clinical outcome of transfemoral embolisation in patients with arteriovenous malformations of the liver in hereditary hemorrhagic telangiectasia (Weber-Rendu-Osler disease).  Gut. 1998;  42 123-126
  PubMedGoogle Scholar
• 61 Trotter J F, Suhocki P V, Lina J R et al.. Hereditary hemorrhagic telangiectasia causing high output cardiac failure: treatment with transcatheter embolization.  Am J Gastroenterol. 1998;  93 1569-1571
  CrossrefPubMedGoogle Scholar
• 62 Stockx L, Raat H, Caerts B et al.. Transcatheter embolization of hepatic arteriovenous fistulas in Rendu-Osler-Weber disease: a case report and review of the literature.  Eur Radiol. 1999;  9 1434-1437
  CrossrefPubMedGoogle Scholar
• 63 Hisamatsu K, Ueeda M, Ando M et al.. Peripheral arterial coil embolization for hepatic arteriovenous malformation in Osler-Weber-Rendu disease; useful for controlling high output heart failure, but harmful to the liver.  Intern Med. 1999;  38 962-968
  CrossrefPubMedGoogle Scholar
• 64 Pfitzmann R, Heise M, Langrehr J M et al.. Liver transplantation for treatment of intrahepatic Osler's disease: first experiences.  Transplantation. 2001;  72 237-241
  CrossrefPubMedGoogle Scholar
• 65 Thevenot T, Vanlemmens C, Di Martino V et al.. Liver transplantation for cardiac failure in patients with hereditary hemorrhagic telangiectasia.  Liver Transpl. 2005;  11 834-838
  CrossrefPubMedGoogle Scholar
• 66 Radtke W E, Smith H C, Fulton R E et al.. Misdiagnosis of atrial septal defect in patients with hereditary telangiectasia (Osler-Weber-Rendu disease) and hepatic arteriovenous fistulas.  Am Heart J. 1978;  95 235-242
  CrossrefPubMedGoogle Scholar
• 67 Neumann U P, Knoop M, Langrehr J M et al.. Effective therapy for hepatic M. Osler with systemic hypercirculation by ligation of the hepatic artery and subsequent liver transplantation.  Transpl Int. 1998;  11 323-326
  PubMedGoogle Scholar
• 68 Willinek W A, Hadizadeh D, von Falkenhausen M et al.. Magnetic resonance (MR) imaging and MR angiography for evaluation and follow-up of hepatic artery banding in patients with hepatic involvement of hereditary hemorrhagic telangiectasia.  Abdom Imaging. 2006;  31(6) 694-700
  CrossrefPubMedGoogle Scholar
• 69 Koscielny A, Willinek W A, Hirner A et al.. Treatment of high output cardiac failure by flow-adapted hepatic artery banding (FHAB) in patients with hereditary hemorrhagic telangiectasia.  J Gastrointest Surg. 2007;  12(5) 872-876
  PubMedGoogle Scholar
• 70 Lerut J, Orlando G, Adam R et al.. liver transplantation for hereditary hemorrhagic telangiectasia: report of the European Liver Transplant Registry.  Ann Surg. 2006;  244 854-864
  CrossrefPubMedGoogle Scholar
• 71 Peck-Radosavljevic M, Zacher J, Meng Y G et al.. Is inadequate thrombopoietin production a major cause of thrombocytopenia in cirrhosis of the liver?.  J Hepatol. 1997;  27 127-131
  CrossrefPubMedGoogle Scholar
• 72 Garcia-Tsao G, Sanyal A J, Grace N D et al.. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.  Hepatology. 2007;  46 922-938
  CrossrefPubMedGoogle Scholar
• 73 Runyon B A. Management of adult patients with ascites due to cirrhosis.  Hepatology. 2004;  39 841-856
  CrossrefPubMedGoogle Scholar
• 74 Lee J Y, Korzenik J R, DeMasi R et al.. Transjugular intrahepatic portosystemic shunts in patients with hereditary hemorrhagic telangiectasia: failure to palliate gastrointestinal bleeding.  J Vasc Interv Radiol. 1998;  9 994-997
  CrossrefPubMedGoogle Scholar
• 75 Chanson N, Carbonell N, Andreani T et al.. TIPS in hereditary hemorrhagic telangiectasia: never say never.  J Hepatol. 2008;  48 373-374
  CrossrefPubMedGoogle Scholar
• 76 Zentler-Munro P L, Howard E R, Karani J, Williams R. Variceal hemorrhage in hereditary haemorrhagic telangiectasia.  Gut. 1989;  30 1293-1297
  CrossrefPubMedGoogle Scholar
• 77 Ludwig J, Kim C H, Wiesner R H et al.. Floxuridine-induced sclerosing cholangitis: an ischemic cholangiopathy?.  Hepatology. 1989;  9 215-218
  CrossrefPubMedGoogle Scholar
• 78 Zajko A B, Campbell W L, Logsdon G A et al.. Cholangiographic findings in hepatic artery occlusion after liver transplantation.  AJR Am J Roentgenol. 1987;  149 485-489
  Google Scholar
• 79 Bauer T, Britton P, Lomas D et al.. Liver transplantation for hepatic arteriovenous malformation in hereditary hemorrhagic telangiectasia.  J Hepatol. 1995;  22 586-590
  CrossrefPubMedGoogle Scholar
• 80 McInroy B, Zajko A B, Pinna A D. Biliary necrosis due to hepatic involvement with hereditary hemorrhagic telangiectasia.  AJR Am J Roentgenol. 1998;  170 413-415
  PubMedGoogle Scholar
• 81 Boillot O, Bianco F, Viale J-P et al.. Liver transplantation resolves the hyperdynamic circulation in hereditary hemorrhagic telangiectasia with hepatic involvement.  Gastroenterology. 1999;  116 187-192
  CrossrefPubMedGoogle Scholar
• 82 Hillert C, Broering D C, Gundlach M et al.. Hepatic involvement in hereditary hemorrhagic telangiectasia: an unusual indication for liver transplantation.  Liver Transpl. 2001;  7 266-268
  CrossrefPubMedGoogle Scholar
• 83 Blewitt R W, Brown C M, Wyatt J I. The pathology of acute hepatic disintegration in hereditary haemorrhagic telangiectasia.  Histopathology. 2003;  42 265-269
  CrossrefPubMedGoogle Scholar
• 84 Lin E, Stall L. Spectrum of biliary abnormalities in hepatic hereditary hemorrhagic telangiectasia: demonstration by multidetector computed tomography.  Emerg Radiol. 2007;  14 461-463
  CrossrefPubMedGoogle Scholar
• 85 Ferenci P, Lockwood A, Mullen K et al.. Hepatic encephalopathy - definition, nomenclature, diagnosis, and quantification: final report of the Working Party at the 11th World Congresses of Gastroenterology, Vienna, 1998.  Hepatology. 2002;  35 716-721
  CrossrefPubMedGoogle Scholar
• 86 Baba Y, Ohkubo K, Hamada K et al.. Hyperintense basal ganglia lesions on T1-weighted images in hereditary hemorrhagic telangiectasia with hepatic involvement.  J Comput Assist Tomogr. 1998;  22 976-979
  CrossrefPubMedGoogle Scholar
• 87 Kobayashi Z, Tani Y, Watabiki S et al.. Brain MRI of hereditary hemorrhagic telangiectasia (HHT) with intrahepatic arteriovenous shunts.  Intern Med. 2005;  44 773-774
  CrossrefPubMedGoogle Scholar
• 88 Yoshikawa K, Matsumoto M, Hamanaka M et al.. A case of manganese induced parkinsonism in hereditary haemorrhagic telangiectasia.  J Neurol Neurosurg Psychiatry. 2003;  74 1312-1314
  CrossrefPubMedGoogle Scholar
• 89 Odorico J S, Hakim M N, Becker Y T et al.. Liver transplantation as definitive therapy for complications after arterial embolization for hepatic manifestations of hereditary hemorrhagic telangiectasia.  Liver Transpl Surg. 1998;  4 483-490
  CrossrefPubMedGoogle Scholar
• 90 Chavan A, Caselitz M, Gratz K F et al. Hepatic artery embolization for treatment of patients with hereditary hemorrhagic telangiectasia and symptomatic hepatic vascular malformations.  Eur Radiol. 2004;  14 2079-2085
  Google Scholar
• 91 Garcia-Tsao G, Gish R G, Punch J. Model for end-stage liver disease (MELD) Exception for hereditary hemorrhagic telangiectasia.  Liver Transpl. 2006;  12(suppl 3) S108-S109
  CrossrefPubMedGoogle Scholar

Guadalupe Garcia-TsaoM.D. 

Section of Digestive Diseases

Yale University School of Medicine, One Gilbert Street, TAC 241-B, New Haven, CT 06510

Email: guadalupe.garcia-tsao@yale.edu