Inhibiting SOX18 with propranolol restores vascular integrity in NR2F2-driven malformations

Translating genomic discoveries into therapies for rare genetic disorders remains a significant challenge, particularly for variants of unknown significance (VUS) where molecular mechanisms are unclear. This is particularly relevant in vascular malformations, where venous differentiation remains poorly understood, and the role of transcription factors in specifying venous identity is only beginning to be elucidated. Here, we combine live-cell single-molecule imaging with genomics-based approaches to uncover a biophysical mechanism of transcription factor antagonism that underpins venous identity. We show that SOX18 and NR2F2 antagonistically co-regulate venous differentiation through dynamic feedback between their nuclear populations. This interaction is disrupted in vascular malformation syndrome caused by a de novo heterozygous NR2F2 mutation, presenting with aberrant vascular integrity and bleeding. Treatment with an FDA-approved drug--known to inhibit SOX18--led to marked clinical improvement in the proband. To dissect the molecular mechanism underlying this mutation and the drug response, we used human embryonic stem cells (hESCs) engineered to carry the probands NR2F2 variant. These cells exhibited impaired hESC to venous differentiation with no effect on artery EC differentiation. In silico modelling and live-cell molecular imaging revealed that the NR2F2 variant is hyper-mobile, fails to form homodimers, and cannot recruit SOX18, thereby disrupting a critical transcriptional antagonism that underpins venous endothelial identity. We demonstrate that targeted pharmacological inhibition of SOX18 restores this regulatory balance in hESC-derived venous endothelial cells, rescuing both gene expression and NR2F2 binding dynamics at the single-molecule level. Together, this study uncovers a biophysical mechanism of transcription factor antagonism that governs venous differentiation and offers a framework for developing targeted therapies for rare vascular malformations.