Bevacizumab to treat complicated liver vascular malformations in hereditary hemorrhagic telangiectasia: A word of caution

✍ Scribed by Elisabetta Buscarini; Guido Manfredi; Alessandro Zambelli

• Publisher: John Wiley and Sons
• Year: 2008
• Tongue: English
• Weight: 45 KB
• Volume: 14
• Category: Article
• ISSN: 1527-6465
• DOI: 10.1002/lt.21656

✦ Synopsis

We read with interest the article by Mitchell et al. 1 dealing with bevacizumab treatment of a patient with hereditary hemorrhagic telangiectasia (HHT), cardiac failure, and portal hypertension due to severe liver vascular malformations (VMs). The treatment reversed the need for liver transplantation.

Despite the undoubtedly inspiring value of this report for future research examining the potential of antiangiogenic drugs in HHT, an appropriate scenario for the use of bevacizumab in the treatment of complicated liver VMs must be clearly detailed.

Important data, which are essential for judging both therapeutic decisions and the treatment outcome, are missing from the case description.

The assessment of the patient's hemodynamic condition should have included a cardiac rhythm description, right heart catheterization data, and pulmonary pressures and vascular resistances. Right heart catheterization should always be performed in patients with HHT who are being evaluated for liver transplantation. 2 The patient therapy description is also unsatisfactory. For example, which diuretics at what dosages were used, what other drugs in addition to beta-blockers were used, and whether anemia was appropriately corrected all remain unclear.

High-output heart failure complicating liver VMs in HHT responds most significantly to intensive medical therapy. This therapy should include the correction of anemia, salt restriction, diuretics, antihypertensive agents, antiarrhythmic agents, and digoxin as clinically indicated. Complications of portal hypertension (in this case, ascites) should be treated as recommended in patients with cirrhosis. 2 Invasive therapies, however, which may be either palliative (eg, transarterial embolization of liver VMs) or curative (eg, liver transplantation), are not current treatment options for advanced symptomatic liver VMs and should be considered only in patients who have failed to respond to intensive medical therapy.