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The field of vascular anomalies has seen a fundamental change during the past 10 years. The identification of somatic genetic mutations as the explanation of sporadic vascular anomalies opened the doors to study prospectively and a posteriori the causes of various vascular malformations. This was helped by the rapidly evolving genetic techniques including the highly sensitive next generation sequencing. In parallel, knowledge on signaling alterations occurring in vascular endothelial cells because of the various mutations, development of in-vitro and especially the first in-vivo models, gave the possibility to test preclinically molecular therapies for vascular malformations.One of the first molecules, rapamycin, showed clear evidence of interrupting lesion growth. As its safety profile had been established in other conditions, it was quickly accepted for clinical trials on vascular anomalies. Now, with a few trials published and others ongoing, it is establishing itself as a gold standard for molecular therapy for recalcitrant lesions.Targeted molecular therapies are becoming interesting new additions to the management of vascular anomalies, and rapamycin is establishing itself as a gold standard for venous malformations.