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Hereditary hemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber disease, is an autosomal dominant disorder of localized angiodysplasia, although it is sometimes mistakenly identified as a hemostatic disorder due to its associated characteristic bleeding. The vascular lesions that develop consist of direct arteriovenous connections without an intervening capillary bed. Germline mutations in one of two different genes, endoglin or ALK-1, can cause HHT. Both are members of the transforming growth factor (TGF)-β receptor family of proteins, and are expressed primarily on the surface of endothelial cells. They are associated together in a receptor complex on the cell surface. Biochemical studies suggest that endoglin modulates TGF-β signaling through ALK-1 and the type I TGF-β receptor. Most mutations identified in endoglin and ALK-1 create null alleles, which lead to reduced message or protein levels. A model of haploinsufficiency is proposed, in which inheritance of a mutation predisposes an individual to develop HHT-associated vascular lesions. The factors that initiate lesion formation are unknown, but disruption of these genes in mice should provide animal models to address these and other important questions about the pathogenesis of HHT.