Do you consider the use of bevacizumab in patients with HHT who have high output cardiac failure related to liver AVMs who also have cerebral AVMs?

Liver and cerebral AVMs are common manifestations in patients with HHT. Treatment of these manifestations should be considered and managed independently. Guideline recommendations to effectively eliminate the future risk of cerebral hemorrhage in patients with cerebral AVMs is consultation with HHT center of excellence and then embolization, microsurgery with stereotactic radiation, or a combination of the two. To my knowledge bevacizumab has not been studied in cerebral AVM patient population. In liver AVMs with known high output heart failure bevacizumab has been studied. Published in JAMA 2012, Dupuis-Girod et al., PMID 22396517 studied 25 patients. They received bevacizumab injections 5mg/kg every 14 days for 6 total doses. At the end of 3 months, they found a statistically significant decrease in CO as measured by echocardiogram. Based on this study, bevacizumab is recommended in the most recent Second International Guidelines for Diagnosis and Management of HHT (Faughnan et al., PMID 32894695). Therefore, the patient noted in the question should receive a procedure for the cerebral AVM and be considered for bevacizumab treatment for the liver AVMs with high output heart failure.