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Small GTP-binding protein Rac is an essential mediator of vascular endothelial growth factor-induced endothelial fenestrations and vascular permeability.

BACKGROUND: Vascular endothelial growth factor/vascular permeability factor (VEGF/VPF) induces both angiogenesis and vascular permeability. Although its angiogenic activity has been well characterized, the signaling pathways of VEGF-induced permeability remain poorly understood. METHODS AND RESULTS: Using the mouse corneal micropocket assay, Miles assay, and a combination of cytochemical, electron microscopic, and biochemical assays, we demonstrate that VEGF-induced vascular leakage partly can be separated from its angiogenic activity. VEGF but not FGF-2 induced capillaries with a highly fenestrated endothelium, a feature linked with increased vascular permeability. A cell-permeable Rac antagonist (TAT-RacN17) converted VEGF-induced, leaky vascular plexuses into well-defined vascular networks. In addition, this Rac mutant blocked formation of VEGF-induced endothelial fenestrations and vascular permeability but only partially inhibited angiogenesis. Studies on endothelial cell cultures further revealed that VEGF stimulated phosphorylation of VEGF receptor-2 (VEGFR-2), leading to activation of Rac as well as increased phosphorylation of phospholipase Cgamma (PLCgamma), protein kinase B (Akt), endothelial nitric oxide synthase (eNOS), and extracellular regulated kinase (Erk1/2). We further found that phosphatidylinositol-3-OH kinase (PI3K) acted upstream of Rac and Akt-eNOS in VEGF/VEGFR-2 signaling. CONCLUSIONS: Our findings indicate that the small GTP-binding protein Rac is a key component in mediation of VEGF-induced vascular permeability but less so in neovascularization. This may have conceptual implications for applying Rac antagonists in treatment and prevention of VEGF-induced vascular leakage and edema in connection with ischemic disorders.

Animals↗

Hemodynamic evaluation before and after closure of fenestrated Fontan. An acute study of changes in oxygen delivery.

BACKGROUND: Acute changes in hemodynamics and oxygen delivery accompanying temporary occlusion of atrial defects in 14 patients after a fenestrated Fontan procedure were evaluated at a median interval of 32 days after surgery to identify candidates for permanent transcatheter closure of their defects. METHODS AND RESULTS: Patients ranged in age from 9 months to 33 years and in weight from 7.9 to 69 kg. Right atrial (RA), left atrial (LA), and aortic pressures, mixed venous (SmvO2) and aortic (SaO2) oxygen saturation, and whole-body oxygen consumption (VO2) were measured, and systemic blood flow (Qs), systemic oxygen transport (SOT), and oxygen extraction were calculated before and after occlusion. SmvO2, VO2, and RA pressures did not change, but SaO2 increased from 84 +/- 6% to 95 +/- 3% (p less than 0.05), and LA pressures fell from 5.1 +/- 3.6 to 3.7 +/- 2.2 mm Hg (p less than 0.05). Qs fell from 2.4 +/- 0.7 to 1.8 +/- 0.41.min-1.m-2 (p less than 0.05), SOT fell from 425 +/- 154 to 366 +/- 112 ml.O2.min-1.m-2 (p less than 0.05), and oxygen extraction increased from 0.40 +/- 0.12 to 0.46 +/- 0.13 (p less than 0.05). Only one patient did not undergo definitive closure of his defect because of a marked decrease in Qs and SOT with a significant rise in RA pressure. CONCLUSIONS: Although delayed closure of an atrial defect in these patients improved morbidity and mortality, the complete separation of the venous and systemic circulations was accomplished at the expense of decreased Qs and oxygen delivery despite the improved level of arterial oxygenation. The resting levels of oxygen extraction are elevated and will be associated with decreased exercise capability. The long-term benefits of closure of these fenestrations are yet to be shown.

Adolescent↗

Fenestrations of the carotid internal elastic lamina and structural adaptation in stroke-prone spontaneously hypertensive rats.

Our aim was to determine the structural factors that determine the mechanical adaptation of the carotid arterial wall in stroke-prone hypertensive rats (SHRSP). Distensibility-pressure and elastic modulus-stress curves assessed by in vivo echo-tracking measurements indicated a reduction in arterial stiffness in 13-week-old SHRSP compared with Wistar-Kyoto rats (WKY). Elastin and collagen contents determined biochemically were not different between SHRSP and WKY. Confocal microscopy showed that the mean area of fenestrations and fraction of area occupied by fenestrations of the internal elastic lamina (IEL) were smaller in SHRSP than in WKY, which indicated a reduction in stress-concentration effects within the IEL. Immunohistologic staining of EIIIA fibronectin isoform and total fibronectin (also as determined by Western blot) was greater in SHRSP, which suggested increased cell-matrix interactions. We suggest that these structural modifications of the vascular wall play a synergistic role in the mechanical adaptation to a high level of stress in SHRSP.

Animals↗

Factors related to pleural effusions after Fontan procedure in the era of fenestration.

BACKGROUND: Significant pleural effusions after the Fontan operation prolong hospital stay, may increase the risk of infection, and may necessitate a pleurodesis procedure. METHODS AND RESULTS: From February 1991 to April 2000, 98 consecutive patients under the age of 18 years underwent the fenestrated Fontan procedure at Children's Hospital of Wisconsin. Ninety-four patients who survived at least 30 days after surgery were retrospectively evaluated for the following factors: age, ventricular morphology (right single ventricle, left single ventricle [RV/LV]), fenestration open (FO) or closed (FC) at end of operation, intracardiac Fontan (IF) or extracardiac Fontan (EF), days with chest tube output per day >5, 10, and/or 20 mL. kg(-1). d(-1) (CTO5, CTO10, and CTO20, respectively), need for pleurodesis, length of hospital stay (LOS), operation during winter respiratory viral season of November through March (ReVS+, ReVS-), and pre-Fontan mean pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR). In univariate analysis, the ReVS+ patients had prolonged LOS, greater chest tube output, and more pleurodesis (P<0.05), and PAP was related to CTO5 and CTO10 but not to CTO20 or LOS. No significant differences were found in LOS, CTO5, CTO10, CTO20, and need for pleurodesis between patients in RV/LV, FO/FC, IF/EF, or PVR groups. Patients <4 years of age had more instances of CTO20 (P<0.05). When we used ordinary least squares regression analysis with age, FO or FC, RV or LV, PAP, and ReVS+ or ReVS- to predict each of CTO5, CTO10, CTO20, and LOS, only ReVS+ or ReVS- and age were statistically significant in all models. CONCLUSIONS: Use of the Fontan procedure during the respiratory viral season appeared to be related to significant, prolonged pleural effusions and longer hospitalizations.

Adolescent↗

Partial resection of atrial septal aneurysm with multiple fenestrations--a case report.

Aneurysms of the interatrial septum are uncommon lesions that are often accompanied by other cardiac anomalies or systemic thrombosis. The authors report 1 case of atrial septum aneurysm that was diagnosed by two-dimensional contrast echocardiography. At surgery a membrane-like, fenestrated aneurysmal protrusion to the right atrium without thrombosis was seen. The atrial septum was closed without using an artificial patch after some of the aneurysm with fenestrations was resected.

Adult↗

Relief of acute lower limb ischemia with percutaneous fenestration of intimal flap in a patient with type III aortic dissection--a case report.

Acute right lower limb ischemia developed in a patient with type III aortic dissection. Aortography revealed complete occlusion of the right common iliac artery by dissecting intima. Immediately percutaneous transfemoral fenestration with angioplasty balloon catheter was performed and marked improvement was obtained in clinical symptoms and angiographic findings. Unfortunately the patient died of rupture of the thoracic aorta about eleven hours after the procedure. The cause of death was not thought to be related to this procedure. The authors conclude that percutaneous fenestration should be considered as the treatment of choice for visceral or limb ischemia due to acute aortic dissection.

Aortic Dissection↗

Postoperative outcome of lumbar spinal canal stenosis after fenestration: correlation with changes in intradural and extradural tube on magnetic resonance imaging.

PURPOSE: To evaluate the serial changes in clinical results and the intradural and extradural spaces on magnetic resonance imaging (MRI) after bilateral fenestration in 48 patients with lumbar spinal canal stenosis (LSCS). METHODS: A prospective interventional study was performed to study the clinical results, magnetic resonance imaging scans among patients who were followed up for more than 3 years. RESULTS: All patients showed improvement in clinical symptoms after operation, but clinical results deteriorated in 9 (19%) patients. Postoperative MRI scans showed that poor dural tube expansion, grouping of the cauda equina, and decrease in the cross-sectional area of the dural tube were factors associated with poor outcomes. The cross-sectional area of the dural tube and images of the cauda equina observed by MRI, before and after fenestration and during follow-up, reflected changes in clinical symptoms involving decompressed segments. CONCLUSION: Serial changes in the cross-sectional area of the dural tube and images of the cauda equina observed preoperatively, postoperatively, and on follow-up by MRI may be useful when evaluating patients' condition before and after operation. It is also useful for predicting outcomes.

Aged↗

Permeability of rat choriocapillaris to hemeproteins. Restriction of tracers by a fenestrated endothelium.

The choriocapillaris is the fenestrated capillary bed in the choroid of the eye and is the major blood supply to the retinal pigment epithelium (RPE) and photoreceptor cells. Bruch's membrane (BM) is a multilaminated basement membrane that separates the choriocapillaris from the RPE. In a previous study (Pino RM, Essner E; Cell Tissue Res 208:21, 1980) we found that the choriocapillary endothelium restricted the egress of ferritin from the choriocapillaris. In the present study, hemeproteins were used to further establish the permeability characteristics of this capillary bed. Horseradish peroxidase (Einstein-Strokes radius (ESR), 30 A) rapidly crossed the capillary endothelium (less than 5 min) after intravenous administration and after 5 minutes filled BM and the basal infoldings of the RPE. In contrast, hemoglobin (Hg) (ESR, 32 A) and lactoperoxidase (LP) (ESR, approximately 40 A) are markedly restricted at the level of endothelial diaphragmed fenestrae, channels, and intercellular junctions. Little vesicular transport of these proteins was observed. The reaction product of the two hemeprotein activities was not demonstrable in BM for up to 30 min after injection; relatively low levels were detected after 75 min. HG and LP appear to be further restricted by BM, since their reaction products were not demonstrable between the RPE basal infoldings at this time. Catalase (ESR, 52 A) activity was not detected in BM for up to 4 hr after injection. These results indicate that the rat choriocapillary endothelium, unlike the fenestrated endothelia lining other vascular beds, substantially restricts the passage of large tracer molecules.

Animals↗

Platypnea-orthodeoxia associated with a fenestrated atrial septal aneurysm: case report.

BACKGROUND: Platypnea-orthodeoxia describes the condition of combined dyspnea and hypoxia respectively, whilst in the upright position, which improves in the recumbent position. CASE REPORT: We present a case of platypnea-orthodeoxia due to a fenestrated atrial septal defect associated with an atrial septal aneurysm. Due to the fenestrated nature of the atrial septal defect, surgical rather than percutaneous correction was performed. CONCLUSION: A high index of suspicion is required to diagnose the syndrome of platypnea-orthodeoxia. Careful echocardiographic evaluation is required to identify the syndrome, and to determine suitability for percutaneous repair.

Aged↗

Fenestration of intraventricular cysts using a flexible, steerable endoscope and the argon laser.

Two infants with hydrocephalus and compartmentalization of the lateral ventricles due to cerebrospinal fluid infection were treated by fenestration of the ventricular cysts using the argon laser through a steerable flexible endoscope. Both children had undergone failed multiple shunting procedures that attempted to drain the lateral ventricular cysts. One child had chronic granulomatous disease and persistent Candida ventriculitis and meningitis. His infection resolved after removal of multiple shunt systems was made possible by endoscopic laser fenestration to convert a multilocular to a unilocular hydrocephalus. Postoperative computed tomographic scans and head circumference measurements showed arrested hydrocephalus in both cases, and both children remain symptom-free 6 months after operation. The argon laser was used to coagulate and incise the ventricular septae in both cases. The steerable flexible endoscope enabled excellent visualization of the ventricular system without manipulation of the endoscope at the corticotomy site. Necessary improvements in the design of the flexible endoscope and the delivery system for the argon laser are discussed.

Brain Diseases↗

Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy: preliminary report.

We describe an operative approach to lumbar canal stenosis which, unlike laminectomy, takes into account the segmental pathology of the disease. At each level involved, a bilateral subarticular fenestration is performed under high magnification. The medial third of each facet joint is first removed with an air-powered drill; then the remaining two-thirds of the joint is undercut with the drill to allow a generous fenestration in the thickened ligamentum flavum and adjacent laminae. All tissue responsible for neural compression is removed, but the spinous processes, interspinous ligaments, and much of the facet joints and laminae are preserved. Spinal stability is maintained and, because tissue disruption is minimized, postoperative discomfort is usually reduced, promoting early mobility and reduced hospital stay. The operation is described in detail, and the results of operation in 32 patients are assessed. The follow-up periods now range from 17 to 58 months. Of 23 patients who presented with neurogenic claudication, 14 (61%) obtained complete relief and 7 (30%) improved significantly. The mean hospital stay was 9 days (range, 4 to 17 days).

Adult↗

A partially thrombosed, fenestrated basilar artery mimicking an aneurysm of the vertebrobasilar junction: case report.

We report a patient with a subarachnoid hemorrhage in whom a partially thrombosed, fenestrated basilar artery mimicked an aneurysm of the vertebrobasilar junction on preoperative angiography. Intraoperatively, no aneurysm was detected; instead, the patient was found to have partial thrombosis of one limb of the fenestrated basilar artery. The nodular appearance of the residual lumen of the vessel corresponded exactly to the angiographic findings. To our knowledge, no similar case has been reported.

Adult↗

[Dissecting aneurysm of the intracranial fenestrated vertebral artery submited to endovascular treatment: case report].

Dissecting aneurysms of the vertebral artery at its intracranial segment are uncommon lesions, mainly when associated to subarachnoid hemorrhage, being also rare fenestrations of the vertebral artery. They present high morbidity and mortality, with high rebleeding rate and difficulty of surgical approach. We present a 19 years old man who was victim of physical aggression in the occipto-cervical region, presenting subarachnoid hemorrhage and a dissecting aneurysm of the right vertebral artery, which had a fenestration, being submitted to endovascular treatment. We accomplished a literature review about this subject, proposing endovascular treatment as a therapeutic option for these cases.

Adult↗

Effect of a collagen matrix on healing in periodontal fenestration defects in dogs.

Contralateral periodontal fenestration defects in seven beagle dogs were used to evaluate influence of a collagen matrix on periodontal wound healing. The defects (6 x 4 mm) were created through the buccal cortical plates of the maxillary canine teeth following elevation of mucoperiosteal flaps. The collagen was fitted to the defects on one side. Contralateral defects served as controls. Flaps were repositioned and sutured. Dogs were sacrificed 4 weeks after surgery and block sections including teeth and surrounding structures were prepared for histometric analysis. No meaningful differences in cementum and bone regeneration were observed between treatments. There was seemingly more bone regeneration in the apical than in the coronal aspect of the defects and significantly more cementum regeneration. Root resorption was observed in one collagen and one control defect. Ankylosis was not observed. The results suggest that the maxillary canine periodontal fenestration defect can be used as a model to evaluate factors that may enhance cementum and bone regeneration. The collagen matrix neither enhanced nor inhibited periodontal wound healing in this model.

Alveolar Bone Loss↗

Esthetic buccal flap for correction of buccal fenestration defects during flapless immediate implant surgery.

BACKGROUND: Clinically, it is a tremendous challenge to create natural gingival esthetics after immediate or delayed implant placement. Hence, flapless immediate implant surgery has been proposed to overcome the shortfalls of these techniques. Nonetheless, one of the major limitations for this technique is its inability to correct localized horizontal/vertical deficiency, dehiscence, or fenestration without jeopardizing esthetic outcomes. Therefore, the aim of this paper was to present a new flap design, the esthetic buccal flap (EBF), aimed at overcoming this potential problem while maintaining the optimal esthetic appearance. METHODS: Five consecutively EBF-treated patients with simultaneous implant placement were included in this pilot case study. Clinical measurements were taken at the time of prosthesis insertion and 6 and 12 months after surgery. These included soft tissue height, papillae appearance, scar appearance, and mid-buccal probing depth. RESULTS: Data obtained from this pilot case study showed that soft tissue height was preserved, and papillae appearance remained the same as at presurgery. No scar tissue was reported in any cases. Mid-buccal probing depths remained consistent throughout the study. CONCLUSION: The results indicate that EBF, together with simultaneously guided bone augmentation, allows clinicians to correct apical buccal fenestration defects while maintaining the supraosseous soft tissue during flapless immediate implant surgery.

Adult↗

Posterior inferior cerebellar artery aneurysm associated with fenestration of the vertebral artery--case report.

A 72-year-old male hospitalized for disturbance of consciousness and vomiting was found to have a left vertebral artery fenestration and a left posterior inferior cerebellar artery aneurysm. The aneurysm was successfully clipped through the lateral suboccipital approach and he recovered with minimal deficits. The association of vertebral artery fenestration and posterior inferior cerebellar artery aneurysm is rare, and their etiologies and relationship are discussed.

Aged↗

Spontaneous occlusion of ruptured vertebral artery dissection at the extradural fenestration associated with extradural origin of the posterior inferior cerebellar artery--case report.

A 69-year-old female suffered from sudden onset of severe headache. Computed tomography showed subarachnoid hemorrhage primarily located in the posterior fossa. Initial angiography demonstrated a fenestration of the vertebral artery and an extracranial origin of the posterior inferior cerebellar artery. However, no bleeding points could be clearly detected. The operative findings revealed a massive clot in subarachnoid space, but no bleeding point. Serial angiography demonstrated dissection in one of the limbs of the fenestrated vertebral artery on the 25th day after the onset. On the 100th day, the lesion was spontaneously occluded. The patient is presently doing well at 8 years after surgery.

Aged↗