Spontaneous dissection of the superior mesenteric artery (SMA) is rare. We report a case of rupture of the SMA after spontaneous dissection in a 51-year-old man who presented with acute onset of abdominal pain and hypotension. The patient was diagnosed as having segmental arterial mediolysis (SAM).

Current treatments for varicose veins and other vascular malformations are to some degree invasive and may therefore be painful and associated with complications such as infection, thrombophlebitis, and bleeding. The development of entirely noninvasive techniques has been hampered by the high cost, large size, and power requirements of candidate technologies, such as high-intensity focused ultrasound (HIFU) imaging. Our group has developed a HIFU device that is hand-held and battery-operated, and we have previously demonstrated that it is capable of venous ablation ex vivo. The purpose of this study was to determine whether it is capable of transcutaneous venous ablation in vivo.

Expression and activity of matrix metalloproteinase (MMP) enzymes is important in the process of venous thrombus resolution. Expression of the membrane-type MMP family of genes (MT-MMPs) in thrombus resolution, and the regulation of their expression by blood flow (recanalization) remain undefined. We tested the hypothesis that thrombus resolution would activate these genes and that recanalization would further regulate their expression.

Adipose-derived stem cells (ASCs) injected into the blood stream after an ischemic event promote therapeutic angiogenesis in affected tissues. It has been suggested that the stem cells exert their influence by way of a paracrine effect on native endothelial cells (ECs). Using an in vitro model, we evaluated the effect of ASC coculture on EC function in a hypoxic environment.

Vascular smooth muscle cell (VSMC) chemotaxis is important in intimal hyperplasia (IH). Nitric oxide (NO), a diffusible molecule that decreases VSMC chemotaxis to several growth factors, is protective against IH. Thrombospondin-1 (TSP-1), a matricellular glycoprotein that induces VSMC chemotaxis, acts antagonistically to NO in VSMCs. Statins exhibit direct and pleiotropic effects on VSMCs. We showed overnight treatment with lovastatin inhibited TSP-1-induced VSMC chemotaxis by mevalonate pathway inhibition and was Ras dependent. Hypothesis: Short-term statin treatment will inhibit TSP-1-induced VSMC chemotaxis and NO donors will enhance statin inhibitory effects.

Although carotid angioplasty is associated with increased adverse events in elderly patients compared with younger patients, some animal models of carotid angioplasty have previously demonstrated only negative remodeling in aged rats compared with younger rats. Therefore, we examined the response to carotid artery angioplasty using a validated animal model of aging.

Angioplasty imparts a cellular response to vascular smooth muscle cells (VSMCs) that contributes to intimal hyperplasia (IH). Previous cell culture manipulation has imputed that apoptosis follows rapid freezing, but no direct plaque sampling has confirmed this. An ex vivo carotid plaque model allows procedure-specific histologic and biologic assessment of metabolically active tissue.

A population-based study by Jetty et al demonstrated a significant reduction in 30-day mortality (adjusted hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.20-0.59) with endovascular repair (EVR) relative to open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) but no significant difference in 5-year mortality (adjusted HR, 0.95; 95% CI, 0.81-1.05). To determine until when the perioperative survival advantage with EVR compared with OSR is sustained, we performed a meta-analysis of randomized controlled trials (RCTs) of EVR vs OSR for AAAs.

We read carefully the article by Jonker et al. entitled “Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm”. Observational studies were retrieved in the meta-analysis. When dealing with meta-analyses, in particular with meta-analyses of nonrandomized data, some key points in the building up process of the analysis must be considered.

We would like to thank Navarese et al for their interest and reaction regarding our meta-analysis about the outcomes of open and endovascular repair of ruptured descending thoracic aortic aneurysms (rDTAA). We agree that meta-analyses of non-randomized studies have considerable limitations, which we have addressed in the limitations section at the end of the article. Currently, no randomized controlled trials or large prospective studies have compared the outcomes of open and endovascular repair of rDTAA, and the optimal approach for this emergency remains unclear. Given the rarity of this condition, and its emergent nature, it will be very difficult to ever realize a randomized study investigating the outcomes of rDTAA after both treatments. In the absence of level I evidence, we decided to perform a meta-analysis of the available studies between 1995 and June 2009, in order to provide more insights into this rare but lethal disease, by reporting the overall results of open and endovascular repair of rDTAA in the literature. Despite the described limitations of such a meta-analysis, we believe that our methodology was adequate and that the article provides a concise summary of the published outcomes, which could, therefore, improve the current knowledge about the management and outcomes of rDTAA.

McNally et al demonstrated, in their retrospective analysis of 401 patients undergoing elective abdominal aortic aneurysm repair, that postoperative mortality rate was significantly decreased in the open repair statin cohort compared with the nonstatin open repair cohort and trended to be decreased in the endovascular repair statin group. Previous meta-analyses, which combined unadjusted odds ratios (ORs) in nonrandomized studies, also suggested that preoperative statin therapy was associated with lower postoperative mortality after vascular surgery. Since these meta-analyses were conducted, however, results of a number of controlled studies have been reported to date. In the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography III (DECREASE III) trial, a recent large randomized double-blind placebo-controlled trial in patients undergoing vascular surgery, perioperative statin therapy reduced not postoperative death but myocardial ischemia or the composite of death from cardiovascular causes and myocardial infarction. Combining not unadjusted but adjusted risk estimates in nonrandomized studies, we performed an updated meta-analysis of controlled studies of preoperative statin therapy for the prevention of postoperative mortality in vascular surgery.

We read the comments from Takagi et al with great interest. Their letter outlines an interesting and thought-provoking meta-analysis demonstrating the protective benefits of preoperative statin therapy in patients with noncoronary vascular disease. In addition to the studies cited in our manuscript, this letter cites several other important sources which add credence to our hypothesis regarding the influence of statin-class drugs on operative outcomes and resource utilization after aneurysm surgery. Takagi et al should be commended for this analysis, and we would urge the authors to consider a robust publication of the methodology and data.

In the August 2010 issue of the Journal of Vascular Surgery (Volume 52, Issue 3), the Trans-Atlantic Debate article entitled “Asymptomatic carotid artery stenosis—Medical therapy alone versus medical therapy plus carotid endarterectomy or stenting” erroneously left Dr. Jean-Baptiste Ricco off of the article as co-section editor. Thomas L. Forbes, MD, and Jean-Baptiste Ricco, MD, PhD, are co-section editors for this article.

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Background: New training paradigms in vascular surgery necessitate medical student interest in vascular disease. We examined the effects of incorporation of a vascular disease educational program during the second year of the medical school curriculum on student acquisition of knowledge and interest in the treatment of vascular disease.Methods: We developed and administered a new educational program on vascular disease and delivered the program to all second-year medical students. The new program encompassed 9 didactic hours, including 7 traditional lecture hours and 2 hours of problem-based learning. After completing the program, students were surveyed regarding vascular disease-specific knowledge, interest in treating vascular disease, and career choices. Third-year students who were not exposed to the program were surveyed as a control group. We recorded the voluntary student enrollment in the vascular and endovascular surgery rotation during the following academic year. Voluntary enrollment of the students exposed to the vascular disease education program was compared with enrollment for the previous 8 years.Results: Before the introduction of the new educational program, 946 total lecture hours were delivered to first- and second-year medical students, comprising 490 hours (52%) given by nonsurgeon physicians, 445 (47%) by nonphysicians, and 11 (1%) by surgeons. Survey response rate was 93% (112 of 121) for second-year students and 95% (39 of 41) for third-year students. After the vascular disease program, second-year students answered 7.1 ± 1.4 of 9 vascular disease questions correctly, whereas unexposed third-year students answered 7.2 ± 1.7 questions correctly (P = .96). Most second-year medical students described a “somewhat” or “much greater” interest in the medical (63%), procedural (59%), and overall (63%) management of vascular disease after exposure to the program. Most also had a “somewhat” or “much greater” interest in a vascular medicine (64%) or vascular and endovascular surgery (60%) rotation. Enrollment in the vascular surgery third-year clerkship increased significantly to a mean of 3.0 students/month from 1.16 students/month in the prior year (P = .0032, postintervention year vs 8 prior years).Conclusion: A vascular disease educational program administered to second-year medical students increases interest in vascular disease and interest in further training. The increased interest translates to greater student enrollment in the vascular surgery clerkship in the subsequent academic year.

Dr Eric D. Endean (Lexington, Ky). I would like to thank Dr Godshall for sending me a copy of their manuscript in advance of the meeting. For a number of years, there has been concern raised regarding the interest in vascular surgery as a career choice of medical students and residents. Indeed, as borne out by the match, the pool of applicants for our programs is limited, and a significant proportion of programs go unmatched. One solution has been to propose and create Vascular Surgery Integrated programs, of which there are currently 21 approved programs. I have wondered how these programs will attract students. In my own experience, vascular surgery is not a specialty that has immediate name recognition. For example, when telling someone that I practice vascular surgery, the typical response I receive is “Oh, you do varicose veins.” Looking back at my own career path, even though I rotated on a vascular surgery service as a third-year medical student, I was unable to commit to a career in vascular surgery until midway through my residency. I have also found that the majority of candidates applying for general surgery are considering fellowship training but are unwilling to commit to a specific area as a medical student.