Gene-specific endothelial programs drive AVM pathogenesis in SMAD4 and ALK1 loss-of-function

BACKGROUND: Hereditary hemorrhagic telangiectasia is a genetic disorder caused by loss-of-function mutations in components of the bone morphogenetic protein signaling pathway, leading to arteriovenous malformations. Most prior work has treated BMP-component mutations as mechanistically interchangeable, yet whether distinct genes converge on a shared mechanism remains unclear. We aimed to understand the molecular relationship between BMP signaling and endothelial flow response that leads to AVM formation. METHODS: We expose human endothelial monolayers treated with siRNA against SMAD4 or ALK1 to laminar flow and analyze flow-responsive transcriptomics, flow-responsive BMP signaling activation dynamics, cell polarity and morphology. We analyze the cell-autonomous and non-cell-autonomous migration dynamics of ECs treated with siSMAD4 or siALK1. Using the postnatal mouse retina model, we study EC distribution changes over time in mosaic settings, and assess the remodelling capabilities of Smad4iECKO or Alk1iECKO, relative to littermate controls. RESULTS: This study shows that mutations in SMAD4 or ALK1 lead to fundamentally distinct mechanisms of malformation formation. SMAD4 deficiency enhances endothelial responses to blood flow, including transcriptional activation and migration against flow, causing excessive capillary pruning and the development of single large shunts. In contrast, ALK1 deficiency disrupts flow sensing, impairs cell polarization and migration, and promotes a persistent angiogenic state, resulting in dense, hypervascularized networks. RNA sequencing reveals that these transcriptional changes precede flow onset, suggesting early defects in endothelial fate specification. Mosaic in vitro models show that mutant cells co-opt neighboring wild-type cells, while in vivo tracking confirms mutation-specific migration behavior. CONCLUSIONS: These findings reveal divergent cellular programs driving arteriovenous malformations and underscore the need for gene-specific diagnostic and therapeutic strategies.