Robot-assisted techniques in vascular and endovascular surgery.

For thousands of years, robots have inspired the imagination of humans, but it was only about 35 years ago that a robot was used for the first time in medicine. Since then, robot-assisted procedures have become increasingly popular in urology, general surgical specialties, and gynecology. Robot-assisted vascular surgery was first introduced in 2002 and was thought to overcome the limitations of laparoscopy. However, it did not gain widespread popularity, and its usage is still limited to a few centers worldwide. Robot-assisted endovascular procedures, on the other hand, while still in its infancy, have become a promising alternative to existing techniques. The improvements of the robotic systems promote better surgical performance and reduce occupational hazards for vascular and endovascular surgeons. A comprehensive review of literature was performed using the search terms "robotic," "robot assisted," "vascular surgery," and "aortic" for surgical procedures or "robotic," "robot assisted," and "endovascular" for endovascular procedures. Full text articles that were published between January 1990 and March 2021 were included. This review summarizes the development of the techniques for robot-assisted vascular and endovascular surgery in recent years, its outcomes, advantages, disadvantages, and perspectives.

Biodegradable polymeric stents for vascular application in a porcine carotid artery model: English version.

Over the past years the development of biodegradable polymeric stents has made great progress; nevertheless, essential problems must still be solved. Modifications in design and chemical composition should optimize the quality of biodegradable stents and remove the weaknesses. New biodegradable poly-L-lactide/poly-4-hydroxybutyrate (PLLA/P4HB) stents and permanent 316L stents were implantedendovascularly into both common carotid arteries of 10 domestic pigs. At 4 weeks following implantation, computed tomography (CT) angiography was carried out to identify the distal degree of stenosis. The PLLA/P4HB group showed a considerably lower distal degree of stenosis by additional oral application of atorvastatin (mean 39.81 ± 8.57 %) compared to the untreated PLLA/P4HB group without atorvastatin (mean 52.05 ± 5.80 %). The 316L stents showed no differences in the degree of distal stenosis between the group treated with atorvastatin (mean 44.21 ± 2.34 %) and the untreated group (mean 35.65 ± 3.72 %). Biodegradable PLLA/P4HB stents generally represent a promising approach to resolving the existing problems in the use of permanent stents. Restitutio ad integrum is only achievable if a stent is completely degraded.

[The role of intensive care medicine in early postoperative complications. Is surgical expertise in danger?]. / Rolle der Intensivmedizin bei frühen postoperativen Komplikationen. Ist die chirurgische Expertise in Gefahr?

Intensive care medicine is the backbone of surgery. We describe a profile of parameters which has to be repeatedly evaluated to allow early detection of postoperative complications. Complex surgical diseases are analyzed to underscore that only a surgeon experienced in intensive care medicine is able to interpret abnormalities in correlation with the intra-operative findings resulting in appropriate decisions with respect to diagnostic measures and reintervention. An increasing lack of motivation compromises the necessary training of young surgeons. Work hour limits already prolong education in the operative core competence thus making residents decline a necessary extension of ICU training beyond the compulsory 6 months. Identification of young surgeons with intensive care medicine is further hampered by the establishment of interdisciplinary operative ICUs excluding surgeons from the leadership. Our current survey of 38 university departments of general and gastro-intestinal surgery in Germany shows that a cooperative ICU steering structure of anesthesiologists and surgeons exists in only 19%. The imminent deficit of training in surgical intensive care medicine can only be counteracted by equal leadership structures.

Differential responsiveness to the chemorepellent Semaphorin 3A distinguishes Ipsi- and contralaterally projecting axons in the chick midbrain.

In the chick dorsal mesencephalon, the optic tectum, the developing axons must choose between remaining on the same side of the midline or growing across it. The ipsilaterally projecting axons, forming the tectobulbar tract, course circumferentially toward the ventrally situated floor plate but before reaching the basal mesencephalon, the tegmentum, gradually turn caudally. Here, they follow the course of the medial longitudinal fasciculus (MLF), located parallel to the floor plate. By in vivo labeling of tectal axons, we could demonstrate that these axons arise primarily in the dorsal tectum. To test the idea that chemorepellent molecules are involved in guidance of the nondecussating axons, we performed coculture experiments employing tectal explants from various positions along the dorso-ventral axis. Axons emanating from dorsal tectal explants were strongly repelled by diencephalic tissue containing the neurons that give rise to the MLF whereas ventral tectal axons showed only a moderate response. This inhibitory effect was substantially neutralized by the addition of anti-neuropilin-1 antibodies. A similar differential response of axons was observed when tectal explants were cocultured with cell aggregates secreting the chemorepellent Semaphorin 3A (Sema3A). Sema3B and Sema3C, respectively, did not inhibit growth of tectal axons. In addition, neither the floor plate nor Slit2-secreting cell aggregates influenced outgrowth of dorsal fibers. In Sema3A-deficient mice, DiI-labeling revealed that dorsal mesencephalic axons cross the MLF instead of turning posteriorly upon reaching the fiber tract, thus behaving like the ventrally originating contralaterally projecting axons. A differential responsiveness of tectal axons to Sema3A most likely released by the MLF thus contributes to pathfinding in the ventral mesencephalon.

Semaphorin 3A-vascular endothelial growth factor-165 balance mediates migration and apoptosis of neural progenitor cells by the recruitment of shared receptor.

The dynamic and coordinated interaction between cells and their microenvironment controls cell migration, proliferation, and apoptosis, mediated by different cell surface molecules. We have studied the response of a neuroectodermal progenitor cell line, Dev, to a guidance molecule, semaphorin 3A (Sema3A), described previously as a repellent-collapsing signal for axons, and we have shown that Sema3A acts as a repellent guidance cue for migrating progenitor cells and, on prolonged application, induces apoptosis. Both repulsion and induction of cell death are mediated by neuropilin-1, the ligand-binding component of the Sema3A receptor. The vascular endothelial growth factor, VEGF165, antagonizes Sema3A-induced apoptosis and promotes cell survival, migration, and proliferation. Surprisingly, repulsion by Sema3A also depends on expression of VEGFR1, a VEGF165 receptor, expressed in Dev cells. Moreover, we found that these repulsive effects of Sema3A require tyrosine kinase activity, which can be attributed to VEGFR1. These results indicate that the balance between guidance molecules and angiogenic factors can modulate the migration, apoptosis (or survival), and proliferation of neural progenitor cells through shared receptors.

Axonal surface molecules act in combination with semaphorin 3a during the establishment of corticothalamic projections.

Interactions between growing axons are considered to play important roles for the establishment of precise neuronal connections during the development of the nervous system. Here we used time-lapse imaging techniques to examine the behavior of neocortical and thalamic axons when they encounter each other in vitro. Results indicate that axonal growth cones are able to respond to specific cues expressed on the surface of fibers. Thalamic growth cones often extended along the surface of other thalamic axons and, likewise, cortical growth cones formed fascicles with cortical axons. In contrast, after contacts between cortical and thalamic fibers, in most cases growth cones collapsed and retracted from the axons. Collapse assays using membrane preparations from cortical or thalamic explants demonstrated the existence of cell-type specific collapsing factors whose activity was enhanced by a member of the semaphorin protein family, Sema3A (expressed in the thalamocortical pathway), as it increased the rate of homotypic fasciculations and at the same time amplified the segregation between cortical and thalamic axons. The interaction between axonal surface molecules and environmental cues might mediate the segregation of afferent and efferent fiber tracts in the neocortical white matter.

The semaphorin 3A receptor may directly regulate the activity of small GTPases.

The axon guidance signal semaphorin 3A induces the rapid collapse of growth cones by activating a receptor complex that contains neuropilin-1 as the ligand-binding and a plexin as the signal-transducing subunit. Here we show that plexins bind Rho-like GTPases and may directly regulate their activity. The cytoplasmic domain of plexins shows sequence similarity to GTPase activating proteins (GAPs) and mutation of two arginines that correspond to the catalytic residues of Ras GAPs inactivates plexin-A1. Our data suggest that plexins may be integral membrane proteins with an intrinsic GAP activity that is essential for their ability to induce growth cone collapse.

Patterning of olfactory sensory connections is mediated by extracellular matrix proteins in the nerve layer of the olfactory bulb.

In early rat embryos when axons from sensory neurons first contact the olfactory bulb primordium, lactosamine-containing glycans (LCG) are detected on neurons that are broadly distributed within the olfactory epithelium, but that project axons to a very restricted region of the ventromedial olfactory bulb. LCG(+) axons extend through channels defined by the coexpression of galectin-1 and beta2-laminin. These two extracellular matrix molecules are differentially expressed, along with semaphorin 3A, by subsets of ensheathing cells in the ventral nerve layer of the olfactory bulb. The overlapping expression of these molecules creates an axon-sorting domain that is capable of promoting and repelling subsets of olfactory axons. Specifically, LCG(+) axons preferentially grow into the region of the nerve layer that expresses high amounts of galectin-1, beta2-laminin, and semaphorin 3A, whereas neuropilin-1(+) axons grow in a complementary pattern, avoiding the ventral nerve layer and projecting medially and laterally. These studies suggest that initial patterning of olfactory epithelium to olfactory bulb connections is, in part, dependent on extracellular components of the embryonic nerve layer that mediate convergence and divergence of specific axon subsets.

Semaphorin 3A is required for guidance of olfactory axons in mice.

Semaphorin 3A (Sema3A) is a membrane-associated secreted protein that has chemorepulsive properties for neuropilin-1 (npn-1)- expressing axons. Although mice lacking the Sema3A protein display skeletal abnormalities and heart defects, most axonal projections in the CNS develop normally. We show here that Sema3A is expressed in the lamina propria surrounding the olfactory epithelium (OE) and by ensheathing cells in the nerve layer of the ventral olfactory bulb (OB) throughout development. Subsets of sensory neurons expressing npn-1 are distributed throughout the OE and extend fibers to the developing OB. In wild-type mice, npn-1-positive (npn-1(+)) axons extend to lateral targets in the rostral OB and medial targets in the caudal OB, avoiding regions expressing Sema3A. In Sema3A homozygous mutant mice, many npn-1(+) axons are misrouted into and through the ventral nerve layer, beginning as early as embryonic day 13 and continuing at least until birth. At postnatal day 0, npn-1(+) glomeruli are atypically located in the ventral OB of Sema3A(-/-) mice, indicating that aberrant axon trajectories are not corrected during development and that connections are made in inappropriate target regions. In addition, subsets of OCAM(+) axons that normally project to the ventrolateral OB and some lactosamine-containing glycan(+) axons that normally target the ventral OB are also misrouted in Sema3A mutants. These observations indicate that Sema3A expression by ensheathing cells plays an important role in guiding olfactory axons into specific compartments of the OB.

Plexin/neuropilin complexes mediate repulsion by the axonal guidance signal semaphorin 3A.

In the developing nervous system axons navigate with great precision over large distances to reach their target areas. Chemorepulsive signals such as the semaphorins play an essential role in this process. The effects of one of these repulsive cues, semaphorin 3A (Sema3A), are mediated by the membrane protein neuropilin-1 (Npn-1). Recent work has shown that neuropilin-1 is essential but not sufficient to form functional Sema3A receptors and indicates that additional components are required to transduce signals from the cell surface to the cytoskeleton. Here we show that members of the plexin family interact with the neuropilins and act as co-receptors for Sema3A. Neuropilin/plexin interaction restricts the binding specificity of neuropilin-1 and allows the receptor complex to discriminate between two different semaphorins. Deletion of the highly conserved cytoplasmic domain of Plexin-A1 or -A2 creates a dominant negative Sema3A receptor that renders sensory axons resistant to the repulsive effects of Sema3A when expressed in sensory ganglia. These data suggest that functional semaphorin receptors contain plexins as signal-transducing and neuropilins as ligand-binding subunits.

Sema3C and netrin-1 differentially affect axon growth in the hippocampal formation.

The interaction between outgrowing neurons and their targets is a central element in the development of the afferent and efferent connections of the hippocampal system. This requires that axonal growth cones recognize specific guidance cues in the appropriate target area. At present, little is known about the mechanisms that determine the lamina-specific termination of hippocampal afferents. In order to understand the role of different guidance factors, we analyzed the effects of Sema3C and Netrin-1 on explants from the entorhinal cortex, dentate gyrus, cornu ammonis regions CA1 and CA3 and medial septum in a collagen coculture assay. Our observations suggest that both semaphorins and netrin play important roles in the neuron-target interactions in the hippocampal system. Sema3C is involved in the control of the ingrowth of the septohippocampal projection. We also show that netrin-1 is involved in attracting commissural neurons from dentate gyrus/hilus and CA3 to their target area in the contralateral hippocampus.

Spatial distributions of guidance molecules regulate chemorepulsion and chemoattraction of growth cones.

It is generally assumed that gradients of chemotropic molecules are instrumental to the wiring of the nervous system. Recently, two members of the secreted class III semaphorin protein family have been implicated as repulsive (Sema3A) and attractive (Sema3C) guidance molecules for cortical axons (). Here, we show that stabilized gradients of increasing semaphorin concentrations elicit stereotyped responses from cortical growth cones, independent of the absolute concentration and the slope of these gradients. In contrast, neither repulsive effects of Sema3A nor attractive effects of Sema3C were observed when axons were growing toward decreasing semaphorin concentrations. Thus, growth cone guidance by gradients of chemotropic molecules is robust and reproducible, because it is primarily independent of the exact dimensions of the gradients.

Semaphorins: repulsive guidance molecules show their attractive side.

Semaphorins are known to repel growth cones of developing axons, but a study of the grasshopper limb bud shows that they can also serve as attractive guidance cues.

Semaphorin D acts as a repulsive factor for entorhinal and hippocampal neurons.

We analysed the effects of semaphorin D on axons from the developing rat entorhinal-hippocampal formation. Explants from superficial layers of the entorhinal cortex and of the hippocampus anlage were obtained from various developmental stages and co-cultured with cell aggregates expressing semaphorin D. Neurites extending from entorhinal explants that had been isolated from early embryonic stages (E16 and E17) were not affected by semaphorin D, but were repelled at later stages (E20 and E21). Axons from hippocampal neurons explanted at E21 were also repelled by semaphorin D. In situ hybridization studies revealed expression of the semaphorin D receptor neuropilin-1 in the entorhinal cortex from stage E17 to stage P7, and in the dentate gyrus and CA1-3 regions between E17 and adulthood. These data suggest that semaphorin D is involved in the formation of the perforant pathway and acts, via the neuropilin-1 receptor, as a repulsive signal that prevents entorhinal fibres from growing into the granular layer of the dentate gyrus. These data also suggest a role for semaphorin D in the development of intrahippocampal connections.

Semaphorins act as attractive and repulsive guidance signals during the development of cortical projections.

Members of the semaphorin family have been implicated in mediating axonal guidance in the nervous system by their ability to collapse growth cones and to function as chemorepellents. The present findings show that recombinant Semaphorin D has similar effects on cortical axons and, in addition, inhibits axonal branching. In contrast, semaphorin E acts as an attractive guidance signal for cortical axons. Attractive effects were only observed when growth cones encountered increasing concentrations or a patterned distribution of Semaphorin E, but not when they are exposed to uniform concentrations of this molecule. Specific binding sites for Semaphorin D and Semaphorin E were present on cortical fibers both in vitro and in vivo at the time when corticofugal projections are established. In situ hybridization analysis revealed that the population of cortical neurons used in our experiments express neuropilin-1 and neuropilin-2, which are essential components of receptors for the class III semaphorins. Moreover, semD mRNA was detected in the ventricular zone of the neocortex whereas semE mRNA was restricted to the subventricular zone. Taken together, these results indicate that semaphorins are bifunctional molecules whose effects depend on their spatial distribution. The coordinated expression of different semaphorins, together with their specific activities on cortical axons, suggests that multiple guidance signals contribute to the formation of precise corticofugal pathways.

Differential patterns of semaphorin expression in the developing rat brain.

Semaphorins are a large family of cell-surface and secreted proteins that have been shown to function as chemorepellents or inhibitors of growth cones of peripheral neurons, yet little is known about their role in patterning central pathways. In order to examine whether semaphorins may be involved in guiding the formation of the reciprocal thalamocortical connections in the rat, we have analysed the spatial and temporal expression of five recently identified rodent semaphorins (semB, C, D, F and G) using in situ hybridization. Transcripts of all five genes were present throughout the period examined (E15-P7) and displayed highly specific spatiotemporal distributions. We have based our discussion of putative semaphorin effects on their known functions as chemorepellents and found their spatiotemporal expression patterns compatible with such a role in several developmental events. Specifically, semaphorins are in the position to: (i) prevent neurite extension into the ventricular neuroepithelium throughout the brain; (ii) confer non-permissive properties to the embryonic cortical plate, hence regulating the radial invasion of corticopetal afferents; (iii) confine axonal extension to the intermediate zone and subplate; (iv) maintain the fasciculated state of thalamocortical and corticothalamic axons, and prevent them from branching while they grow through the striatum; and (v) restrict the terminal arborizations of thalamic afferents to layer IV. The evidence that different semaphorin genes are often co-expressed further suggests that the various molecules might interact in synergistic ways. Taken together, our results support the hypothesis that semaphorins could act as guidance signals in the development of the thalamocortical projections and suggest that innervation specificity is achieved through the combined action of multiple guidance cues. Furthermore, these data provide a basis for the design of functional assays and the study of mice carrying knockouts in specific semaphorin genes.

The chemorepulsive activity of the axonal guidance signal semaphorin D requires dimerization.

The axonal guidance signal semaphorin D is a member of a large family of proteins characterized by the presence of a highly conserved semaphorin domain of about 500 amino acids. The vertebrate semaphorins can be divided into four different classes that contain both secreted and membrane-bound proteins. Here we show that class III (SemD) and class IV semaphorins (SemB) form homodimers linked by intermolecular disulfide bridges. In addition to the 95-kDa form of SemD (SemD(95k)), proteolytic processing of SemD creates a 65-kDa isoform (SemD(65k)) that lacks the 33-kDa carboxyl-terminal domain. Although SemD(95k) formed dimers, the removal of the carboxyl-terminal domain resulted in the dissociation of SemD homodimers to monomeric SemD(65k). Mutation of cysteine 723, one of four conserved cysteine residues in the 33-kDa fragment, revealed its requirement both for the dimerization of SemD and its chemorepulsive activity. We suggest that dimerization is a general feature of sema- phorins which depends on class-specific sequences and is important for their function.

Molecular cloning and mapping of human semaphorin F from the Cri-du-chat candidate interval.

Cri-du-chat is a human contiguous gene deletion syndrome resulting from hemizygous deletions of chromosome 5p. Here we describe the isolation from within this interval of the human Semaphorin F (SEMAF) gene, a member of a family of proteins that has been implicated in axonal pathfinding. The human SEMAF gene covers at least 10% of the deleted region and defines a new class within this large gene family characterized by the presence of seven type 1 thrombospondin repeats. Prominent expression of murine semaphorin F (Semaf) was observed in the mouse brain, consistent with a role for semaphorin F as a signaling molecule that guides axons or migrating neuronal precursors during development. The known functions of semaphorins and the interesting pattern of expression for Semaf suggest that haploinsufficiency for SEMAF may disrupt normal brain development and might lead to some of the features of Cri-du-chat.

The chemorepulsive activity of secreted semaphorins is regulated by furin-dependent proteolytic processing.

The semaphorins are a large group of cell surface and secreted proteins implicated in axonal pathfinding. Here we show that the secreted mouse semaphorin D (SemD) is synthesized as an inactive precursor (proSemD) and becomes repulsive for sensory and sympathetic neurites upon proteolytic cleavage. ProSemD processing can be blocked completely by an inhibitor selective for furin-like endoproteases or mutagenesis of three conserved dibasic cleavage sites. Its C-terminal pro-peptide contains a processing signal that is essential for SemD to acquire its full repulsive activity. SemD processing is regulated during the embryonic development of the mouse and determines the magnitude of its repulsive activity. Similarly to SemD, the secreted semaphorins SemA and SemE display repulsive properties that are regulated by processing. Our data suggest that differential proteolytic processing determines the repulsive potency of secreted semaphorins and implicate proteolysis as an important regulatory mechanism in axonal pathfinding.