Vascular Ehlers-Danlos Syndrome

Clinical characteristics: Vascular Ehlers-Danlos syndrome (vEDS) is characterized by arterial, intestinal, and/or uterine fragility; thin, translucent skin; easy bruising; characteristic facial appearance (thin vermilion of the lips, micrognathia, narrow nose, prominent eyes); and an aged appearance to the extremities, particularly the hands. Vascular dissection or rupture, gastrointestinal perforation, or organ rupture are the presenting signs in most adults with vEDS. Arterial rupture may be preceded by aneurysm, arteriovenous fistulae, or dissection but also may occur spontaneously. The majority (60%) of individuals with vEDS who are diagnosed before age 18 years are identified because of a positive family history. Neonates may present with clubfoot, hip dislocation, limb deficiency, and/or amniotic bands. Approximately half of children tested for vEDS in the absence of a positive family history present with a major complication at an average age of 11 years. Four minor diagnostic features – distal joint hypermobility, easy bruising, thin skin, and clubfeet – are most often present in those children ascertained without a major complication.

Diagnosis/testing: The diagnosis of vEDS is established in a proband by identification of a heterozygous pathogenic variant in COL3A1, or, when molecular genetic testing does not identify a COL3A1 pathogenic variant, on biochemical analysis of type III procollagen from cultured fibroblasts.

Management: Treatment of manifestations: Affected individuals are instructed to seek immediate medical attention for sudden, unexplained pain. Treatment may include medical or surgical management for arterial complications, bowel rupture, or uterine rupture during pregnancy.

Surveillance: May include periodic arterial screening by ultrasound examination, magnetic resonance angiogram, or computed tomography angiogram with and without venous contrast. Blood pressure monitoring on a regular basis is recommended to allow for early treatment if hypertension develops.

Agents/circumstances to avoid: Trauma (collision sports, heavy lifting, and weight training with extreme lifting); arteriography should be discouraged and used only to identify life-threatening sources of bleeding prior to surgical intervention because of the risk of vascular injury; routine colonoscopy in the absence of concerning symptoms or a strong family history of colon cancer; elective surgery unless the benefit is expected to be substantial.

Evaluation of relatives at risk: The genetic status of at-risk relatives should be clarified through molecular genetic testing or clinical evaluation if the pathogenic variant is unknown.

Pregnancy management: Affected women have a 5% mortality risk with each pregnancy. The issue of management and recommendations is complicated by the recognition that many of the women who became pregnant, and their providers, learn of the diagnosis at the time of delivery and the onset of complications. When the mother’s diagnosis is known, maternal risks should be discussed and she should be followed in a high-risk obstetric program.

Other: Affected individuals should carry documentation of their genetic diagnosis, such as a MedicAlert^®, emergency letter, or vEDS "passport."

Genetic counseling: Vascular EDS is almost always inherited in an autosomal dominant manner, but rare examples of biallelic inheritance have been reported. About 50% of affected individuals have inherited the COL3A1 pathogenic variant from an affected parent, and about 50% of affected individuals have a de novo pathogenic variant. Each child of an affected individual has a 50% chance of inheriting the pathogenic variant and developing the disorder. Prenatal testing for a pregnancy at increased risk and preimplantation genetic testing are possible in families in which the pathogenic variant in COL3A1 has been identified.