Vascular malformations, which result from anomalies in angiogenesis, include capillary, lymphatic, venous, arteriovenous, and mixed malformations and affect specific vessel types. Historically, treatments such as sclerotherapy and surgery have shown limited efficacy in complicated cases. Most vascular malformations occur sporadically, but some can be inherited. They result from mutations similar to oncogenic alterations, activating pathways such as PI3K-AKT-mTOR or Ras-MAPK-ERK. Recognizing these parallels, we highlight the potential of targeted molecular inhibitors, repurposing anticancer drugs for the treatment of vascular malformations. This case-based review explores recent developments in precision medicine for slow-flow and fast-flow vascular malformation.

1.
Mulliken
JB
,
Glowacki
J.
Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics
.
Plast Reconstr Surg
.
1982
;
69
(
3
):
412
-
422
.
2.
Queisser
A
,
Seront
E
,
Boon
LM
,
Vikkula
M.
Genetic basis and therapies for vascular anomalies
.
Circ Res
.
2021
;
129
(
1
):
155
-
173
.
3.
Boscolo
E
,
Limaye
N
,
Huang
L
, et al.
Rapamycin improves TIE2-mutated venous malformation in murine model and human subjects
.
J Clin Invest
.
2015
;
125
(
9
):
3491
-
3504
.
4.
Limaye
N
,
Wouters
V
,
Uebelhoer
M
, et al.
Somatic mutations in angiopoietin receptor gene TEK cause solitary and multiple sporadic venous malformations
.
Nat Genet
.
2009
;
41
(
1
):
118
-
124
.
5.
Seront
E
,
Boon
LM
,
Vikkula
M.
TEK-related venous malformations
. In:
Adam
MP
,
Mirzaa
GM
,
Pagon
RA
, et al
, eds.
GeneReviews
.
University of Washington
;
1993
.
6.
Vikkula
M
,
Boon
LM
,
Carraway KL
III
, et al.
Vascular dysmorphogenesis caused by an activating mutation in the receptor tyrosine kinase TIE2
.
Cell
.
1996
;
87
(
7
):
1181
-
1190
.
7.
Soblet
J
,
Kangas
J
,
Nätynki
M
, et al.
Blue rubber bleb nevus (BRBN) syndrome is caused by somatic TEK (TIE2) mutations
.
J Invest Dermatol
.
2017
;
137
(
1
):
207
-
216
.
8.
Limaye
N
,
Kangas
J
,
Mendola
A
, et al.
Somatic activating PIK3CA mutations cause venous malformation
.
Am J Hum Genet
.
2015
;
97
(
6
):
914
-
921
.
9.
Revencu
N
,
Boon
LM
,
Dompmartin
A
, et al.
Germline mutations in RASA1 are not found in patients with Klippel-Trenaunay syndrome or capillary malformation with limb overgrowth
.
Mol Syndromol
.
2013
;
4
(
4
):
173
-
178
.
10.
Kurek
KC
,
Luks
VL
,
Ayturk
UM
, et al.
Somatic mosaic activating mutations in PIK3CA cause CLOVES syndrome
.
Am J Hum Genet
.
2012
;
90
(
6
):
1108
-
1115
.
11.
Seront
E
,
Van Damme
A
,
Legrand
C
, et al.
Preliminary results of the European multicentric phase III trial regarding sirolimus in slow-flow vascular malformations
.
JCI Insight
.
2023
;
8
(
21
):
e173095
.
12.
Venot
Q
,
Blanc
T
,
Rabia
SH
, et al.
Targeted therapy in patients with PIK3CA-related overgrowth syndrome
.
Nature
.
2018
;
558
(
7711
):
540
-
546
.
13.
Amyere
M
,
Aerts
V
,
Brouillard
P
, et al.
Somatic uniparental isodisomy explains multifocality of glomuvenous malformations
.
Am J Hum Genet
.
2013
;
92
(
2
):
188
-
196
.
14.
Boon
LM
,
Mulliken
JB
,
Enjolras
O
,
Vikkula
M.
Glomuvenous malformation (glomangioma) and venous malformation: distinct clinicopathologic and genetic entities
.
Arch Dermatol
.
2004
;
140
(
8
):
971
-
976
.
15.
Mäkinen
T
,
Boon
LM
,
Vikkula
M
,
Alitalo
K.
Lymphatic malformations: genetics, mechanisms and therapeutic strategies
.
Circ Res
.
2021
;
129
(
1
):
136
-
154
.
16.
Martinez-Corral
I
,
Zhang
Y
,
Petkova
M
, et al.
Blockade of VEGF-C signaling inhibits lymphatic malformations driven by oncogenic PIK3CA mutation
.
Nat Commun
.
2020
;
11
(
1
):
2869
.
17.
Zenner
K
,
Jensen
DM
,
Dmyterko
V
, et al.
Somatic activating BRAF variants cause isolated lymphatic malformations
.
HGG Adv
.
2022
;
3
(
2
):
100101
.
18.
Lala
S
,
Mulliken
JB
,
Alomari
AI
,
Fishman
SJ
,
Kozakewich
HP
,
Chaudry
G.
Gorham-Stout disease and generalized lymphatic anomaly–clinical, radiologic, and histologic differentiation
.
Skeletal Radiol
.
2013
;
42
(
7
):
917
-
924
.
19.
Trenor
CC
,
Chaudry
G.
Complex lymphatic anomalies
.
Semin Pediatr Surg
.
2014
;
23
(
4
):
186
-
190
.
20.
Rodriguez-Laguna
L
,
Agra
N
,
Ibañez
K
, et al.
Somatic activating mutations in PIK3CA cause generalized lymphatic anomaly
.
J Exp Med
.
2019
;
216
(
2
):
407
-
418
.
21.
Barclay
SF
,
Inman
KW
,
Luks
VL
, et al.
A somatic activating NRAS variant associated with kaposiform lymphangiomatosis
.
Genet Med
.
2019
;
21
(
7
):
1517
-
1524
.
22.
Foster
JB
,
Li
D
,
March
ME
, et al.
Kaposiform lymphangiomatosis effectively treated with MEK inhibition
.
EMBO Mol Med
.
2020
;
12
(
10
):
e12324
.
23.
Manevitz-Mendelson
E
,
Leichner
GS
,
Barel
O
, et al.
Somatic NRAS mutation in patient with generalized lymphatic anomaly
.
Angiogenesis
.
2018
;
21
(
2
):
287
-
298
.
24.
Nozawa
A
,
Ozeki
M
,
Niihori
T
,
Suzui
N
,
Miyazaki
T
,
Aoki
Y.
A somatic activating KRAS variant identified in an affected lesion of a patient with Gorham-Stout disease
.
J Hum Genet
.
2020
;
65
(
11
):
995
-
1001
.
25.
Ozeki
M
,
Aoki
Y
,
Nozawa
A
, et al.
Detection of NRAS mutation in cell-free DNA biological fluids from patients with kaposiform lymphangiomatosis
.
Orphanet J Rare Dis
.
2019
;
14
(
1
):
215
.
26.
Li
D
,
Wenger
TL
,
Seiler
C
, et al.
Pathogenic variant in EPHB4 results in central conducting lymphatic anomaly
.
Hum Mol Genet
.
2018
;
27
(
18
):
3233
-
3245
.
27.
Coccia
E
,
Valeri
L
,
Zuntini
R
, et al.
Prenatal clinical findings in RASA1- related capillary malformation-arteriovenous malformation syndrome
.
Genes (Basel)
.
2023
;
14
(
3
):
549
.
28.
Gallipoli
A
,
MacLean
G
,
Walia
JS
,
Sehgal
A.
Congenital chylothorax and hydrops fetalis: a novel neonatal presentation of RASA1 mutation
.
Pediatrics
.
2021
;
147
(
3
):
e2020011601
.
29.
Liu
M
,
Smith
CL
,
Biko
DM
, et al.
Genetics etiologies and genotype phenotype correlations in a cohort of individuals with central conducting lymphatic anomaly
.
Eur J Hum Genet
.
2022
;
30
(
9
):
1022
-
1028
.
30.
Byrne
AB
,
Brouillard
P
,
Sutton
DL
, et al.
Pathogenic variants in MDFIC cause recessive central conducting lymphatic anomaly with lymphedema
.
Sci Transl Med
.
2022
;
14
(
634
):
eabm4869
.
31.
Li
D
,
March
ME
,
Gutierrez-Uzquiza
A
, et al.
ARAF recurrent mutation causes central conducting lymphatic anomaly treatable with a MEK inhibitor
.
Nat Med
.
2019
;
25
(
7
):
1116
-
1122
.
32.
Shaheen
MF
,
Tse
JY
,
Sokol
ES
, et al.
Genomic landscape of lymphatic malformations: a case series and response to the PI3Kα inhibitor alpelisib in an N-of-1 clinical trial
.
Elife
. 5 July
2022
;
11
.
33.
Seront
E
,
Froidure
A
,
Revencu
N
, et al.
Targeted treatment in complex lymphatic anomaly: a case of synergistic efficacy of trametinib and sirolimus
.
Orphanet J Rare Dis
.
2024
;
19
(
1
):
199
.
34.
Lee
MS
,
Liang
MG
,
Mulliken
JB
.
Diffuse capillary malformation with overgrowth: a clinical subtype of vascular anomalies with hypertrophy
.
J Am Acad Dermatol
.
2013
;
69
(
4
):
589
-
594
.
35.
Shirley
MD
,
Tang
H
,
Gallione
CJ
, et al.
Sturge-Weber syndrome and port-wine stains caused by somatic mutation in GNAQ
.
N Engl J Med
.
2013
;
368
(
21
):
1971
-
1979
.
36.
Goss
JA
,
Konczyk
DJ
,
Smits
P
, et al.
Diffuse capillary malformation with overgrowth contains somatic PIK3CA variants
.
Clin Genet
.
2020
;
97
(
5
):
736
-
740
.
37.
De Bortoli
M
,
Queisser
A
,
Pham
VC
, et al.
Somatic loss-of-function PIK3R1 and activating non-hotspot PIK3CA mutations associated with capillary malformation with dilated veins (CMDV)
.
J Invest Dermatol
.
2024
;
144
(
9
):
2066
-
2077.e6
.
38.
De Bortoli
M
,
Ivars
M
,
Revencu
N
, et al.
Epilepsy with faint capillary malformation or reticulated telangiectasia associated with mosaic AKT3 pathogenic variants
.
Am J Med Genet A
.
2024
;
194
(
6
):
e63551
.
39.
Revencu
N
,
Boon
LM
,
Mendola
A
, et al.
RASA1 mutations and associated phenotypes in 68 families with capillary malformation-arteriovenous malformation
.
Hum Mutat
.
2013
;
34
(
12
):
1632
-
1641
.
40.
Amyere
M
,
Revencu
N
,
Helaers
R
, et al.
Germline loss-of-function mutations in EPHB4 cause a second form of capillary malformation-arteriovenous malformation (CM-AVM2) deregulating RAS-MAPK signaling
.
Circulation
.
2017
;
136
(
11
):
1037
-
1048
.
41.
Mologousis
MA
,
Ostertag-Hill
CA
,
Haimes
H
,
Fishman
SJ
,
Mulliken
JB
,
Liang
MG
.
Spectrum of lymphatic anomalies in patients with RASA1-related CM-AVM
.
Pediatr Dermatol
.
2023
;
40
(
6
):
1028
-
1034
.
42.
Couto
JA
,
Huang
AY
,
Konczyk
DJ
, et al.
Somatic MAP2K1 Mutations are associated with extracranial arteriovenous malformation
.
Am J Hum Genet
.
2017
;
100
(
3
):
546
-
554
.
43.
Nikolaev
SI
,
Vetiska
S
,
Bonilla
X
, et al.
Somatic activating KRAS mutations in arteriovenous malformations of the brain
.
N Engl J Med
.
2018
;
378
(
3
):
250
-
261
.
44.
Paolacci
S
,
Mattassi
RE
,
Marceddu
G
, et al.
Somatic variant analysis identifies targets for tailored therapies in patients with vascular malformations
.
J Clin Med
.
2020
;
9
(
11
):
3387
.
45.
Nguyen
HL
,
Boon
LM
,
Vikkula
M.
Trametinib as a promising therapeutic option in alleviating vascular defects in an endothelial KRAS-induced mouse model
.
Hum Mol Genet
.
2023
;
32
(
2
):
276
-
289
.
46.
Boon LM
DV
,
Coulie
J
,
Marot
L
, et al.
Case report study of thalidomide therapy in 18 patients with severe arteriovenous malformation
.
Nature Cardiovasc Res
.
2022
;
1
:
562
-
567
.
47.
Ola
R
,
Dubrac
A
,
Han
J
, et al.
PI3 kinase inhibition improves vascular malformations in mouse models of hereditary haemorrhagic telangiectasia
.
Nat Commun
.
2016
;
7
:
13650
.
48.
Balachandar
S
,
Graves
TJ
,
Shimonty
A
, et al.
Identification and validation of a novel pathogenic variant in GDF2 (BMP9) responsible for hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations
.
Am J Med Genet A
.
2022
;
188
(
3
):
959
-
964
.
49.
Yehia
L
,
Eng
C.
PTEN hamartoma tumor syndrome
. In:
Adam
MP
,
Mirzaa
GM
,
Pagon
RA
, et al
, eds.
GeneReviews
.
University of Washington
;
1993
.
50.
Dompmartin
A
,
Acher
A
,
Thibon
P
, et al.
Association of localized intravascular coagulopathy with venous malformations
.
Arch Dermatol
.
2008
;
144
(
7
):
873
-
877
.
51.
Revencu
N
,
Eijkelenboom
A
,
Bracquemart
C
, et al.
Assessment of gene- disease associations and recommendations for genetic testing for somatic variants in vascular anomalies by VASCERN-VASCA
.
Orphanet J Rare Dis
.
2024
;
19
(
1
):
213
.
You do not currently have access to this content.