Experimental studies demonstrated a severe cardiac load of the CO2 pneumoperitoneum caused by an accelerated after- and a decreased preload. Patients displaying cardiovascular risks are therefore often rejected from laparoscopic surgery. Hence, the pathophysiological changes and the intraoperative risk of the CO2 pneumoperitoneum in high-risk cardiopulmonary patients (NYHA II-III, n = 15) undergoing laparoscopic cholecystectomy are described. The changes in cardiac after- and preload seem to be due to the elevated intraabdominal pressure rather than transperitoneally resorbed CO2 and are reversible by desufflation. In one patient conversion to open operation had to be performed because of a severe drop in cardiac output and right ventricle ejection fraction. Mixed oxygen saturation was predicting intraoperative worsening in this case. The described pathophysiological changes may seem to be well tolerated even in high-risk cardiac patients. Monitoring of hemodynamics should include an arterial catheter line and blood gas analyses. Pharmacologic interventions or pressureless laparoscopic procedures might not be necessary as long as laparoscopic cholecystectomy is performed.

Vascular malformations cause discomfort and pain in children and are often associated with skeletal hypertrophy. Their molecular basis is poorly understood. Ephrin ligands and Eph receptor tyrosine kinases are involved in embryonic vascular development. In mice, some ephrin/Eph family members show a complementary expression pattern in blood vessels, with ephrinB2 being expressed on arterial and EphB4 on venous endothelium. Targeted deletions of the genes reveal their essential roles for conduit vessel development in mice, suggesting similar functions during human vascular development and deregulation in vascular malformations. Here, we have defined the expression patterns of human ephrinB2, EphB4, and EphB2 in normal vessels of neonates (i.e. umbilici) and adults and compared them with those in congenital venous malformations. In adults, normal vessels of the skin, muscle, and legs express ephrinB2 and EphB2 on arterial endothelial cells (ECs), whereas EphB4 is found in arteries and veins. In the umbilicus, EphB2 is a specific marker of arterial ECs, whereas ephrinB2 is additionally expressed in venous ECs, suggesting an arterial function of the veins. In venous malformations, the expression of EphB4 is not altered, but both ephrinB2 and EphB2 are ectopically expressed in venous ECs. This may reflect a nonphysiologic arterialization of malformed veins. Our study shows that the arterial markers ephrin B2 and EphB2 are expressed in a subset of veins, and it remains to be studied whether this is cause or consequence of an altered vascular identity. (Pediatr Res 57: 537-544, 2005) Abbreviations EC, endothelial cell SAM, sterile ␣ motif ␣-SMA, ␣-smooth muscle actin SMC, smooth muscle cell During embryogenesis, blood vessels form via two distinct processes, vasculogenesis and angiogenesis (1-5). Vasculogenesis involves the de novo development of endothelial cells (ECs) from mesodermal precursors, the angioblasts, and leads to the formation of the early vascular plexus. Later, blood vessels arise mainly from the preexisting ones by sprouting, splitting, and intussusceptive growth of capillaries in a process called angiogenesis. Remodeling of the primary vascular plexus into conduit vessels and capillaries ensures perfusion of all organs and tissues with blood. In the adult, angiogenesis accounts for neovascularization accompanying cyclic reproductive changes in women, as well as pathologic processes such as tumor growth, diabetic retinopathy, and rheumatoid arthritis (6,7).To date, three growth factor families have been identified as critical players of blood vessel development: vascular endothelial growth factors, angiopoietins, and ephrins (8,9). Unlike vascular endothelial growth factors and angiopoietins, which are secreted proteins, ephrins are attached to the plasma membrane and function in cell-cell communication (10). Ephrins can be divided into two subclasses: EphrinA ligands (ephrinA1-A5) are tethered to the outer cell surface via a glycosylphosphatidylinositol anchor, whereas ephrinB ligands (ephrinB1-B3) po...

Aortic dissection following AVR is likely to represent a distinct clinical entity which can be predicted and possibly prevented at AVR.

Congenital predominantly venous malformations should be treated according to the principles developed during the past decades in vascular surgery, interventional treatment and multidisciplinary treatment. The days of predominantly conservative treatment should be relegated to the past. Special skills and experiences are necessary to carry out appropriate surgical strategy, and the required operative techniques should be dictated by the location and type of malformation and associated findings.

Purpose To study the efficacy and safety of a new sclerosing gel of absolute ethanol in the percutaneous treatment of venous malformations (VM). Materials and MethodsIn this prospective, non-randomized multicenter study patients with clinically and by magnetic resonance imaging diagnosed VM were treated. Efficacy of the gel was compared with spontaneous evolution of the test lesion during a previous 2 month control period. Therapeutic outcome was compared with published historical data from VM treated with absolute ethanol solution. Blood ethanol levels of ethanol were measured after each infusion. Local and systemic adverse events were recorded. ResultsSeventy five (75) patients (age 4 -46 y, mean 26 y) were treated in 172 sessions. Compared to no treatment, ethanol gel showed a cure rate of about 15% per session (p<0.00001). At the end of the last session, therapeutic outcome was complete (score 2) and partial (score 1) in 28 (37%) and 42 patients (56%), respectively, whereas treatment failure (score 0) was observed in 5 patients (7%). Compared to published historical data with absolute ethanol, results were in favor of the gel (p<0.003). The plasmatic eth -1), with only one patient above the legal 0.5 g/L intoxication limit (0.6 g.L-1). Forty six (46) product-related adverse events (all local, none systemic) were reported. All local complications resolved spontaneously, except for 2 skin necroses requesting surgical paring. ConclusionEthanol gel is a embosclerosing substance that provides high efficiency and improves safety of ethanol in the treatment of VM lesions. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 2 E-Mail: martin.schumacher.nrad @uniklinik-freiburg. de 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 3 Treatment of venous malformations: First experience with a new sclerosing agenta multicenter study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 4 Abstract PurposeTo study the efficacy and safety of a new sclerosing gel of absolute ethanol in the percutaneous treatment of venous malformations (VM). Materials and MethodsIn this prospective, non-randomized multicenter study patients with clinically and by magnetic resonance imaging diagnosed VM were treated. Efficacy and safety of the gel was evaluated. Therapeutic outcome was judged at day 56 after the last sclerosing therapy. Blood ethanol levels of ethanol were measured after each infusion. Local and systemic adverse events were record...