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There is very little literature to guide the young practitioner in caring for a child that needs emergency surgery and has difficult venous access. Questionnaires were sent to 89 members of the Swiss Paediatric Anaesthesia Society and to the heads of Anaesthesia Departments of Swiss teaching hospitals. Two typical case records were presented, both of which were characterised by the fact that 2-3 peripheral venous cannulation attempts were unsuccessful. Case A: a young child with a fracture of the radius and case B an infant with upper gastrointestinal ileus. The anaesthetists were then questioned regarding their preferences for optimal treatment. The majority would proceed with further attempts and, if these still failed, intramuscular or inhalational induction of anaesthesia was suggested as a reasonable choice for case A. However, for case B, a femoral venous or intraosseous access to the venous system was judged to be the safest method. On the basis of our inquiry and a literature search, a priority list was developed to suggest the best possible techniques for vascular access and alternative anaesthesia induction techniques for emergency paediatric procedures.

Currently, vascular lesions are being classified either as tumors with inherent proliferative potential or as vascular malformations with early manifestation and growth commensurate with the growth of the child. This new classification is also applicable to skeletal vascular lesions. 30% of all skeletal vascular lesions manifest in the first two decades of life, with a preponderance of malformations. They are attributed to disturbances in the complex cascade of angiogenesis and a minority may be hereditary. Multiple cutaneous vascular malformations are associated with mutations of the TIE2- and Glomulin-Genes. Vascular malformations with involvement of multiple skeletal elements may pursue an aggressive course and manifest as massive osteolysis. Among the epithelioid vascular tumours of bone, also in young patients, benign epithelioid hemangioma can be distinguished on a morphological basis from epithelioid hemangioendothelioma as an entity with low malignant potential.

Aim: Vascular malformations can be studied in detail by colour Doppler sonography. These lesions are best treated by Nd:YAG laser therapy. The aim of the study was to improve the quality of therapy by the use of colour Doppler sonography guided Nd-YAG laser application., Patients and Method: 17 vascular malformations/haemangiomas in 16 patients were treated by colour Doppler sonography guided Nd:YAG laser therapy. 5 children were less than one year of age, 4 children were between one and five years of age, the other patients were adults (age 22-57 years). The size of the vascular malformations (largest diameter) were 1.5-3 cm (8 cases), all others were larger than 3 cm., Results: When using laser therapy in combination with colour Doppler sonography it is possible to adjust the treatment variables (dose, duration and energy of the laser pulse as well as the precise intralesional positioning) individually. As a result more than 80% of cases can be treated successfully during a single session. Larger lesions may be divided into functional units which can be treated subsequently., Conclusion: Through colour Doppler sonography it is possible to monitor the effects of laser treatment in vascular malformations. The development of smaller ultrasound probes has facilitated the application of laser therapy guided by Doppler sonography in the region of the head and neck. Colour Doppler sonography guided laser therapy increases efficiency and selectivity of the laser treatment. Early interventions prevent growth of the lesions and reduce long-term disfigurement particularly in children.

Just at a time, when practical education and post-graduate training is really a permanent problem, it is necessary to pay attention again and again to the rare problems, which also appear in the doctor's office. They are by far not only "rare and useless": The recognition by the physician may be vital for the patient. Four examples from daily practice illustrate the significance of rarities in the physician's office as a permanent challenge.

Based on experience in arteriography of the hand in 108 patients the authors present in a retrospective study the surgical indications (trauma, tumour, angiodysplasia, malformation and embolic lesion) and results of this method. The diagnostic value of arteriography of the hand is shown by means of results and examples.

Among 9343 colonoscopic examinations (1975-1983) colonic angiodysplasias (AD) were diagnosed in 78 patients (0.8%). The mean age of patients with AD was 68 (17-86) years which was significantly higher than that of patients without AD (p less than 0.0001). 76% of the AD were localized in cecum or colon ascendens, 13% in colon transversum, 4% in colon descendens and 6% in sigmoid colon. 69 patients (88.5%) had 1-4 AD; 4 (5.1%) 5-10 AD and 5 (6%) more than 10 AD. A high incidence of associated diseases leading to vascular complications (i.e. hypertension, diabetes mellitus) was noted. 14 of the 78 patients had anticoagulation or bleeding disorders, possibly precipitating intestinal bleeding. The 21 patients (26.9%) with symptomatic AD had either lower intestinal bleeding (n = 8) or severe anemia (n = 13). In 57 patients (73.1%) the AD were asymptomatic during a mean follow-up of 48 (1-108) months. Whereas age and sex distribution were not significantly different between symptomatic and asymptomatic patients, the number and size of AD were significantly increased in symptomatic patients (p less than 0.005).

Thirty-five cases of aberrant subclavian artery were observed in 1408 consecutive necropsies on fetuses, newborns, infants and children; the autopsies were performed by the same pathologist. The right subclavian artery was found to be involved in 32 cases, the left subclavian artery in 3 cases. The artery always passed behind the esophagus. In 12 of the cases, the aberrant subclavian artery occurred as an isolated anomaly. In the remainder of the cases the aberrant subclavian artery was associated with malformations of the heart and the great vessels; coexistent extracardial defects were also noted. Of the 35 cases 13 were males and 22 females. In reviewing the literature a series of 431 cases is presented. Of these cases the aberrant subclavian artery occurred in 177 males and 254 females. The predominance in females is statistically established.

Excretion urograms were prepared subsequent to angiocardiograph in a total of 115 cardiac catheter examinations. 104 of these examinations were evaluated. In 17 cases (16.3%), malformation of the kidney or the ureter was found. In consideration of the fact that such fundings are often directly linked to therapeutic consequences (plastic operations), the additional preparation of an excretion urogram is indicated during cardiac catheter examinations.

In a prospective study, angiodysplasias were looked for in 824 patients during total coloscopy. Such angiodysplasias were discovered in 30 patients (3.6%). The endoscopic morphology varied, most of the angiodysplasias being smaller than 5 mm (23 patients), with a homogeneous structure in 19, spider-like extensions in only 11 patients. In 13 patients there were multiple angiodysplasias. Two or more segments of the colon were affected in 7 patients. Site of lesions was as follows: in 19 patients in the caecum and/or ascending colon; descending colon, sigmoid and/or rectum in 16; transverse colon in 3 patients. Histological confirmation was obtained in 9 of 20 patients who had a biopsy. Right-sided colectomy for bleeding angiodysplasias (resulting in anaemia) is indicated only if endoscopic coagulation has failed and other colorectal sources of bleeding (neoplasm, diverticulum or polyp) and especially angiodysplasias in the left colon or rectum have been excluded by endoscopy or angiography.

Reported on tumourlike circular focus opacities in the thoracic X-ray photogramms of 34 patients, 27 of them were discovered by mass x-ray surveys. They include: 13 organoid tumours, 1 bronchial adenoma, 2 mucodermoid, 1 cystic adenocarcinoma of bronchus, 1 fibroma, 1 reticulo-cytoma, 1 bronchial papilloma, 7 cystic tumours, partially located in the mediastinum, 3 intrapulmonary malformations of blood vessels, 1 mediastinal neurinoma, and 3 cases with suspicion of organoid tumours. 29 patients had to undergo an operation. Finally the authors give a review of literature of indication for surgical treatment, and they represent guidelines for the medical expert assessment fitness for the National Service.

Angiodysplasia of the colon with preferential localisation in the region the ileocoecal valve is not infrequently the cause of massive gastrointestinal bleeding. The diagnostic problems of this disease are illustrated by seven cases. Contrary to angiography, coloscopy, which may have to be done as an emergency procedure, frequently does not allow localisation of the haemorrhage. Vascular malformations can be demonstrated by arteriography even in the asymptomatic interval. They frequently escape macroscopic identification even in the resected specimen due to their small size and their localisation in the submucosa. The diagnosis can be established histologically by serial sections with vascular filling if necessary. The treatment of choice is resection of the affected part of the gut. In cases of decreased operability endoscopic laser coagulation can be indicated.

Among the various types of hepatic ductular atresias, there is a group of patients with a definable syndrome of malformations: typical physiognomy, malformation of pulmonary arteries, mental retardation and disturbed growth of body and genitals. This syndrome has been defined only in the last two years by Watson et al. (1973) and Allagille et al. (1975). A detailed description of a boy with this combination of malformations is given. Additionally he has aplasia of the right kidney. A second patient out of 4, which we found in our cardiologic department, has hypoblasia of one kidney, too. The prognosis of the liver disease in these patients seems to be better than in other children with biliary atresia.

Congenital angiodysplasias are frequently accompanied by arteriovenous shunts. Large direct shunts between arteries and veins may determine the destiny of the affected limb. They are easily detectable by clinical methods. Small multiple anastomoses, however, may necessitate special investigation methods (circulatory tests) for detection. A hemodynamic influence of multiple small shunts has not yet been proved, but it is well known that they are the cause of intraoperative hemorrhages and of local recurrences of hemangiomas in spite of apparently radical removal. Small arteriovenous anastomoses are not easily detected by routine histology methods. Even in series sections they may be difficult to identify, because the blood vessels in angiodysplasias are poorly differentiated and the small shunts are well hidden in cavernous hemangiomas. Various types of arteriovenous shunts may occur in congenital angiodysplasias. Small shunts were found in all the examined cases, even when they had not been detected clinically by special circulatory tests.

Malformations of different parts of the cartilage results in achondrogenesis II, thanatophoric dwarfism and in metatropic dwarfism. Whether the base of the skull or the cranial-distal skeleton are affected, both together or separately, depends upon the localization of the defect within the cartilage. The different types of the cloverleaf syndrome are characterised by a defect of vessels and cartilage that affect the chondrocranium and the cranial-distal skeleton in different grades. The mal-development of the vessel-system is particularly marked in the upper back of the calotte.

As a result of the autopsy reports of a twenty-year-period from 1960 to 1979 there were 7.1% (n = 324) malformations of the heart and vascular system among 4,561 autopsies of still-born children and live-born ones up to their 16th years of age. Septal defects of the heart are most commonly observed. The malformations were classified and discussed according to nature, combinations and sex differences as well as with respect to importance for mortality, territorial and time distribution.