Objetivos: O objetivo desse estudo foi comparar a perviedade da artéria torácica interna esquerda (ATIE) dissecada por videotoracoscopia robótica para revascularização minimamente invasiva do ramo interventricular anterior (RIA) com a revascularização do miocárdio convencional. Métodos: De 2007 a 2010, 36 pacientes foram randomizados para revascularização do miocárdio minimamente invasiva (RMMI) ou revascularização do miocárdio convencional (RMC). Pacientes randomizados para o grupo RMMI foram submetidos à dissecção da ATIE por videotoracoscopia auxiliada pelo braço robótico AESOP seguida de uma minitoracotomia anterior esquerda no 4º espaço intercostal para anastomose com o RIA. Pacientes randomizados para o grupo RMC foram submetidos a revascularização do miocárdio convencional com esternotomia mediana completa, dissecção aberta da ATIE e anastomose ao RIA. Fluxometria por tempo de trânsito (FTT) foi utilizada para avaliação da perviedade da ATIE imediata. Após 24 meses uma tomografia multislice foi utilizada para avaliar a perviedade a médio prazo da ATIE. Resultados: O tempo médio de dissecção da ATIE no grupo RMMI foi de 50,1 ± 11,2 vs. 22,7 ± 3,3 min no grupo RMC. Não houve diferença significativa no fluxo médio da ATIE para o RIA entre os grupos estudados (46,17 ± 20,11 vs. 48,61 ± 23,42 mL/min, p=0,86) respectivamente. Não houve diferença significante na incidência de infecção de ferida profunda (0 vs. 2, p=0,48) e necessidade de reoperação por sangramento (0 vs. 1, p=1,00) nos grupos RMMI e RMC respectivamente. A angiotomografia mostrou perviedade da ATIE em 100% dos pacientes do grupo RMMI vs. 94,1% no grupo RMC (p=1,00). Não houve mortalidade nos grupos estudados. Conclusão: A revascularização do miocárdio minimamente invasiva do ramo interventricular anterior com dissecção da artéria torácica interna esquerda por videotoracoscopia robótica foi segura e factível. A perviedade da artéria torácica interna esquerda imediata e a médio prazo foi similar entre ambas as técnicas / Objective: The aim of this study was to compare the patency of left internal mammary artery (LIMA) robotically harvested for left anterior descendent (LAD) artery minimally invasive bypass with conventional LIMA to LAD off-pump bypass. Method: From 2007 to 2010, 36 patients were randomized to either LIMA robotically harvested to LAD artery minimally invasive bypass or standard LIMA to LAD off-pump bypass. Patients assigned to robotic group underwent robotic endoscopic harvesting of LIMA with the AESOP system followed by a small left thoracotomy in the 4th intercostal space for off-pump LAD bypass. Patients assigned to standard group underwent full median sternotomy, open LIMA harvesting followed by off-pump LAD bypass. Transit time flow measurement was used for intraoperative evaluation of LIMA to LAD patency. After a mean 24-month follow-up, Multislice Computed Tomography was used to evaluate LIMA to LAD midterm patency. Results: The mean LIMA harvesting time in robotic group was 50.1 ± 11.2 min vs. 22.7 ± 3.3 min in conventional group. There was no significant difference in intraoperative LIMA to LAD flow between robotic and conventional groups (46.17 ± 20.11 mL/min vs. 48.61 ± 23.42 mL/min, p=0.86). There were no significant differences in incidence of wound infection (0 vs. 2, p=0,48) and reoperation for bleeding (0 vs. 1, p=1.00) between robotic and conventional groups respectively. In robotic group, Multislice CT revealed patent LIMA graft in 100% patients vs. 94.1% patients in conventional group (p=1.00). There was no mortality in the study group. Conclusions: Minimally invasive LAD bypass using LIMA graft robotically harvested was safe and feasible. Early and mid-term LIMA patency was similar between both techniques

Objetivos: O objetivo deste estudo é analisar a perviedade da artéria torácica interna direita (ATID) pediculada, anteroaórtica em anastomose para a região anterior do coração na cirurgia de revascularização do miocárdio (RM), em relação à artéria torácica interna esquerda (ATIE). Métodos: No período de dezembro de 2008 a dezembro de 2011, 100 pacientes foram selecionados para serem submetidos a cirurgia de RM sem circulação extracorpórea (CEC), de forma prospectiva. Eles foram agrupados em Grupo 1 (G-1) e Grupo 2 (G-2), cada um com 50 pacientes, com randomização por computador e conhecimento da técnica no início da cirurgia. No G-1, os pacientes receberam ATIE para a região anterior do coração e complementação da RM com a ATID livre para ramos da circunflexa (CX) e outros enxertos arteriais ou venosos para a coronária direita (CD) e/ou ramos. Os pacientes do G-2 receberam ATID pediculada para a região anterior do coração e complementação da RM com ATIE, pediculada, para ramos da CX e outros enxertos arteriais ou venosos para a CD e/ou ramos. A perviedade das artérias torácicas internas direita e esquerda foi avaliada através de angiotomografia coronária multislice, 64 canais, no 6º mês de pós-operatório. Resultados: Os dois grupos eram semelhantes quanto aos dados clínicos de pré-operatório, como exemplo: diabetes mellitus, hipertensão arterial sistêmica, obesidade. Os dois grupos apresentaram predominância do sexo masculino com 75,6% e 88% nos grupos 1 e 2, respectivamente. Cinco pacientes migraram do G-1 para o G-2 em virtude de doença ateromatosa na aorta ascendente e um deles foi excluído por ter que utilizar enxerto composto. A média de anastomoses distais no G-1 foi de 3,48 (DP=0,72), e no G-2 foi de 3,20 (DP=0,76). Não ocorreu mediastinite em nenhum paciente. Uma paciente do G-1 apresentou osteomielite, e necessitou de intervenção cirúrgica. Dois pacientes do G-1 foram submetidos a reoperação por sangramento. Os resultados das angiotomografias coronarianas com 96 pacientes re-estudados mostram que todas as ATIs, fosse a direita ou a esquerda, utilizadas pediculadas para a região anterior do coração encontravam-se sem oclusões ou estenoses, configurando 100% de perviedade. No G-1, um enxerto livre da ATID para ramos da CX apresentava oclusão total, em dois pacientes havia estenose leve, em um deles havia estenose moderada na anastomose proximal na aorta ascendente e outro apresentava diminuição de calibre na sua porção distal. Em três pacientes o enxerto de segmento de veia safena para ramos da CD se encontravam ocluídos. No G-2, dois pacientes apresentavam oclusão total na ATIE pediculada para ramos da CX, e outro apresentava estenose moderada na porção distal da ATIE utilizada sequencial para dois ramos marginais. Em dois pacientes o enxerto de segmento de veia safena para ramos da CD se encontravam ocluídos. Não houve óbitos em nenhum dos grupos. Conclusão: A cirurgia de RM com utilização da ATID pediculada, anterógrada para o RIA, apresenta resultado semelhante ao da ATIE utilizada para essa mesma coronária. / Objective: To analyze the patency of the pedicled, anteroaortic, right internal mammary artery (RIMA) anastomosed to the left anterior descending (LAD) and branches in coronary artery bypass graft surgery (CABG), in comparison with the left internal mammary artery (LIMA). Methods: From December 2008 to December 2011, 100 patients were selected to undergo a prospective off-pump coronary artery bypass graft surgery and were randomly divided by computer into Group 1 (G-1) and Group 2 (G-2), so that the technique was known at the beginning of the surgery. In each group, with 50 patients, the patency of both right and left internal mammary arteries, which were used pedicled to the LAD, was comparatively studied through coronary computed tomography angiography. G-1 had 50 patients who received the LIMA to the LAD or LAD/diagonal (sequential) and had the CABG complemented with the free RIMA to circumflex branches and other arterial or venous grafts to the right coronary artery (RCA) and/or branches. G-2 had 50 patients who received the pedicled RIMA to the LAD or LAD/diagonal (sequential) and had the CABG complemented with the pedicled LIMA to circumflex branches and other arterial or venous grafts to the RCA and/or branches. Results: Both groups were similar in pre-operative clinical data, such as: diabetes mellitus, systemic arterial hypertension, obesity. Also, there was predominance of males in both groups, with 75,6% and 88% in Groups 1 and 2 respectively. Five patients were switched from G-1 to G-2 owing to atheromatous disease in the ascending aorta, and one of them was dropped for having to use composite graft. The average of distal anastomosis in G-1 was 3,48 (standard deviation (SD=0,72) and in G-2 was 3,20 (SD=0,76). Mediastinitis didn\'t occur in any patient. A patient from G-1 had osteomyelitis that required surgical intervention. Two patients from G-1 underwent reoperation because of bleeding. The 64-slice coronary computed tomography angiography was performed in the 6th postoperative month; 96 patients have been re-studied so far and all pedicled IMAs to the LAD were patent. In G-1 a free RIMA graft to the circumflex branches presented total occlusion, another two had a discreet stenosis and in one moderate at the proximal anastomosis and one more had a string signal at the distal portion. In G-2 two patients had total occlusion of the pedicled LIMA to circumflex artery branches, and another one presented moderate stenosis at its distal portion. In two patients the saphenous vein graft to the RCA branches were occluded. There were no deaths in any of the groups. Conclusion: The CABG surgery using the pedicled, anteroaortic RIMA to the LAD has a similar outcome to that of the LIMA used for this same coronary.

Cardiovascular disease varies by ethnicity in the UK. South Asians (SA) have higher coronary heart disease (CHD) and diabetes prevalence, while African-Caribbeans (AfC) have greater stroke, but intriguingly lower CHD rates despite higher blood pressures and diabetes risk than Europeans. Conventional risk factors do not fully explain such differences. This cross-sectional study tested the hypothesis that the hormones, vitamin D measured as 25(OH)D and aldosterone, would be independently associated with intermediate cardiovascular outcome markers in these ethnic groups. Community-dwelling men 40-80 years old (AfC: n=67, 55±10yr; SA: n=68, 55±10yr; European: n=63, 57±8yr) were sampled from Greater Manchester’s multi-ethnic population. The intermediate markers examined were aortic pulse wave velocity (aPWV), left ventricular (LV) mass and function, and carotid intima media thickness (CIMT), measured non-invasively by ultrasound, and hemodynamic profiling methods (the Arteriograph) in the total sample and by magnetic resonance imaging (MRI) in a subsample of 50. Adjusted for age, systolic blood pressure and diabetes, mean(SE) aPWV by the Arteriograph, was 0.5(0.2) m/s higher in SA than AfC and Europeans (p=0.01), which paralleled known cross-ethnic CHD risk differences in the UK. By MRI, aPWV along the descending aorta in SA was 0.7(0.3) and 0.8(0.3) m/s higher than that in AfC and Europeans, but aPWV along the aortic arch was not significantly different. Unlike aldosterone, 25(OH)D was independently and inversely correlated with aPWV (unstandardised B(SE)=-0.013[0.004] m/s, p<0.001), and partly explained the ethnic variation in aPWV. Similar inverse correlations were found between 25(OH)D and LV concentricity measured by echocardiography and MRI. Compared to Europeans, SA and AfC, had 21(3) and 14(3) nmol/L lower mean(SE) 25(OH)D, respectively (p<0.01). Mean(SE) of relative wall thickness, an index of LV concentricity by echocardiography, was 0.05(0.01) higher in SA and AfC than Europeans. Lower 25(OH)D levels were also associated with higher myocardial deformation rates measured by MRI myocardial tagging (n=50), supporting previous animal experimental evidence. A one standard deviation (SD) decrease in 25(OH)D was associated with a 0.38 SD increase in absolute systolic strain rate (p=0.003) and 0.22 SD rise in diastolic strain rate (p=0.04). Right and left CIMT showed different relations with 25(OH)D and aldosterone. Left-right CIMT differences varied by ethnicity and were related to SA ethnicity and aldosterone levels. Two related technical studies investigated the relatively new method of hemodynamic profiling, the Arteriograph, used here. The results suggested a standardisation method of aortic length estimation for purely central aPWV, which significantly improved aPWV agreement between the Arteriograph and MRI (reference method here), and was used for calibrating the Arteriograph aPWV in the above-mentioned results for the total sample. Future well-designed trials are necessary to investigate any cause-effect relationship between vitamin D deficiency and the unfavourable cardiovascular intermediate outcomes found here in a cross-sectional design and multi-ethnic background.

Background: Patients with carotid artery dissection (CAD) have been reported to have different vascular risk factor profiles and clinical outcomes to those with vertebral artery dissection (VAD). However, there are limited data from recent, large international studies comparing risk factors and clinical features in patients with cervical artery dissection (CeAD) with other TIA or ischemic stroke (IS) patients of similar age and sex. Methods: We analysed demographic, clinical and risk factor profiles in TIA and IS patients ≤ 55 years of age with and without CeAD in the large European, multi-centre, Stroke In young FAbry Patients 1 (sifap1) study. Patients were further categorised according to age (younger: 18–44 years; middle-aged: 45–55 years), sex, and site of dissection. Results: Data on the presence of dissection were available in 4,208 TIA and IS patients of whom 439 (10.4%) had CeAD: 196 (50.1%) had CAD, 195 (49.9%) had VAD, and 48 had multiple artery dissections or no information regarding the dissected artery. The prevalence of CAD was higher in women than in men (5.9 vs. 3.8%, p < 0.01), whereas the prevalence of VAD was similar in women and men (4.6 vs. 4.7%, n.s.). Patients with VAD were younger than patients with CAD (median = 41 years (IQR = 35–47 years) versus median = 45 years (IQR = 39–49 years); p < 0.01). At stroke onset, about twice as many patients with either CAD (54.0 vs. 23.1%, p < 0.001) or VAD (63.4 vs. 36.6%, p < 0.001) had headache than patients without CeAD and stroke in the anterior or posterior circulation, respectively. Compared to patients without CeAD, hypertension, concomitant cardiovascular diseases and a patent foramen ovale were significantly less prevalent in both CAD and VAD patients, whereas tobacco smoking, physical inactivity, obesity and a family history of cerebrovascular diseases were found less frequently in CAD patients, but not in VAD patients. A history of migraine was observed at a similar frequency in patients with CAD (31%), VAD (27.8%) and in those without CeAD (25.8%). Conclusions: We identified clinical features and risk factor profiles that are specific to young patients with CeAD, and to subgroups with either CAD or VAD compared to patients without CeAD. Therefore, our data support the concept that certain vascular risk factors differentially affect the risk of CAD and VAD.

Indiana University-Purdue University Indianapolis (IUPUI) / Obesity increases cardiovascular disease risk and is associated with factors of the “metabolic syndrome” (MetS), a disorder including hypertension, hypercholesterolemia and/or impaired glucose tolerance. Expanding adipose and subsequent inflammation is implicated in vascular dysfunction in MetS. Perivascular adipose tissue (PVAT) surrounds virtually every artery and is capable of releasing factors that influence vascular reactivity, but the effects of PVAT in the coronary circulation are unknown. Accordingly, the goal of this investigation was to delineate mechanisms by which lean vs. MetS coronary PVAT influences vasomotor tone and the coronary PVAT proteome. We tested the hypothesis that MetS alters the functional expression and vascular contractile effects of coronary PVAT in an Ossabaw swine model of the MetS. Utilizing isometric tension measurements of coronary arteries in the absence and presence of PVAT, we revealed the vascular effects of PVAT vary according to anatomical location as coronary and mesenteric, but not subcutaneous adipose tissue augmented coronary artery contractions to KCl. Factors released from coronary PVAT increase baseline tension and potentiate constriction of isolated coronary arteries relative to the amount of adipose tissue present. The effects of coronary PVAT are elevated in the setting of MetS and occur independent of endothelial function. MetS is also associated with substantial alterations in the coronary PVAT proteome and underlying increases in vascular smooth muscle Ca2+ handling via CaV1.2 channels, H2O2-sensitive K+ channels and/or upstream mediators of these ion channels. Rho-kinase signaling participates in the increase in coronary artery contractions to PVAT in lean, but not MetS swine. These data provide novel evidence that the vascular effects of PVAT vary according to anatomic location and are influenced by the MetS phenotype.

No description available.

Indiana University-Purdue University Indianapolis (IUPUI) / Peripheral arterial disease is caused by plaque buildup in the peripheral arteries. Standard treatments are available when the blockage is proximal and focal, however when distal and diffuse the same type of the treatment options are not beneficial due to the diseased locations. Restoration of blood flow and further salvaging of the limb in these patients can occur in a retrograde manner through the venous system, called retroperfusion or arteriovenous reversal. Retroperfusion has been explored over the last century, where early side to side artery to venous connections had issues with valve competency prohibiting distal flows, edema buildup, and heart failure. However, more recent clinical studies create a bypass to a foot vein to ensure distal flows, and though the results have been promising, it requires a lengthy invasive procedure. It is our belief that the concerns of both retroperfusion approaches can be overcome in a minimally invasive/catheter based approach in which the catheter is engineered to a specific resistance that avoids edema and the perfusion location allows for valves to be passable and flow to reach distally. In this approach, the pressure flow relations were characterized in the retroperfused venous system in ex-vivo canine legs to locate the optimal perfusion location followed by in-vivo validation of canines. Six canines were acutely injured for 1-3 hours by surgical ligation of the terminal aorta and both external iliac arteries. Retroperfusion was successfully performed on five of the dogs at the venous popliteal bifurcation for approximately one hour, where flow rates at peak pressures reached near half of forward flow (37±3 vs. 84±27ml/min) and from which the slope of the P/F curves displayed a retro venous vasculature resistance that was used to calculate the optimal catheter resistance. To assess differences in regional perfusion, microspheres were passed during retroperfusion and compared to baseline microspheres passed arterially prior to occlusion in which the ratio of retroperfusion and forward perfusion levels were near the ratio of reversed and forward venous flow (0.44) throughout the limb. Decreases in critical metabolites during injury trended towards normal levels post-retroperfusion. By identifying the popliteal bifurication as a perfusion site to restore blood flow in the entirety of the distal ischemic limb, showing reversal of injury, and knowing what catheter resistances to target for further chronic studies, steps towards controlled retroperfusion and thus more efficient treatment options can be made for severe PAD patients.

Η οπτική συνεκτική τομογραφία με τη χρήση συχνοτήτων ( FD-OCT) είναι μια ενδαγγειακή απεικονιστική μέθοδος που χρησιμοποιεί εγγύς στο υπέρυθρο φως, για να παράγει υψηλής ανάλυσης εικόνες του τοιχώματος του αυλού του αγγείου. Όπως και στην τεχνολογία υπερήχων, εκπέμπεται φωτεινή ενέργεια η οποία ανακλάται και εξασθενεί, σύμφωνα με την υφή του προσπιπτομένου ιστού. Το OCT μπορεί να απεικονίσει, με ανάλυση από 10 έως 20 μm, μικροδομές του αγγειακού τοιχώματος με εξαίσια λεπτομέρεια. Μέχρι σήμερα, η δυνατότητα εφαρμογής της μεθόδου είχε περιοριστεί σε μικρές αρτηρίες διαμέτρου έως 4mm και δεν είχε εφαρμοστεί in vivo στα αγγεία των κάτω άκρων, κάτωθεν του επιπέδου των βουβώνων. Σκοπός της παρούσας μελέτης είναι να αναφερθεί για παγκοσμίως πρώτη φορά η ασφάλεια και η σκοπιμότητα της απεικόνισης με Οπτική Συνεκτική Τομογραφία του αρτηριακού άξονα των κάτω άκρων , κάτωθεν του επιπέδου της βουβώνας ( μηροϊγνυακός άξονας και κνημιαία αγγεία), καθώς και οι σχετιζόμενες με το FD-OCT επιπλοκές. Επιπρόσθετα, να διερευνηθούν για πρώτη φορά, με τη χρήση FD-OCT, τα χαρακτηριστικά του αγγειακού τοιχώματος του ανωτέρω άξονα (τόσο πριν όσο και μετά από αγγειοπλαστική ή/και τοποθέτηση stent), η μορφολογία της αθηρωματικής πλάκας, η μορφολογία και η ποσοτικοποίηση της υπερπλασίας του νέου εσωτερικού χιτώνα (neointima) εντός του stent, η επαναστένωση εντός του stent (ISR) και η κακή εναπόθεση (malapposition) των stent struts σε μια σειρά από ασθενείς που πάσχουν από περιφερική αρτηριοπάθεια (PAD). Μελετήθηκαν, με ποσοτική ανάλυση του αυλού τους (Quantitative vascular analysis), αρτηρίες με διάμετρο έως 7 χιλιοστά. Μικτά χαρακτηριστικά από περιοχές πλούσιες σε λιπίδια, εναποθέσεις ασβεστίου και ασβεστοποιημένες πλάκες, νεκρωτικές περιοχές και ίνωση εντοπίστηκαν σε όλες τις απεικονιζόμενες αθηροσκληρωτικές βλάβες. Ωστόσο, με βάση το επικρατέστερο από τα παραπάνω απεικονιστικά χαρακτηριστικά, οι βλάβες στο πλαίσιο της έρευνας ταξινομήθηκαν ως αμιγώς ινωτικές, ως ινοασβεστοποιημένες, ως πλούσιες σε λιπίδια και τέλος ως νεκρωτικές/ασβεστοποιημένες. Συσσώρευση των μακροφάγων εντός της αθηρωματικής πλάκας σημειώθηκε σε μικρό ποσοστό των de novo αθηρωματικών αλλοιώσεων. Ποικίλοι βαθμοί υπερπλασίας του νέου έσω χιτώνα απεικονίσθηκαν σε όλες τις περιπτώσεις ISR αλλοιώσεων, με καθαρά ινωτικά χαρακτηριστικά και σημαντική νεοαγγείωση σε κάποιες από αυτές. Η νεοαγγείωση συνέπεσε με το επίπεδο της μέγιστης στένωσης του αγγειακού αυλού. Σημαντικού βαθμού διαχωρισμός με μεγάλο περιορισμό του αγγειακού αυλού, τέτοιος ώστε να απαιτηθεί να τοποθετηθεί ενδοαυλικό stent, ανιχνεύθηκε σε αρκετές περιπτώσεις της de novo αθηρωμάτωσης. Η ψηφιακή αφαιρετική αγγειογραφία παρέλειψε να προσδιορίσει μεγάλο ποσοστό των σοβαρών διαχωρισμών μετά από αγγειοπλαστική. Η νεοαθηροσκλήρυνση εντός του νέου έσω χιτώνα των κνημιαίων φαρμακευτικών stents (DES), είναι ένα συχνό εύρημα τόσο στους συμπτωματικούς όσο και στους ασυμπτωματικούς ασθενείς. Μπορούμε να υποθέσουμε ότι, κατά αναλογία με τα εμφυτευμένα DES στα στεφανιαία αγγεία, η ελαττωματική ενδοθηλιοποίηση που προκαλείται από την εκλυόμενη φαρμακευτική ουσία, μαζί με την νεοαγγείωση που αναπτύσσεται μεταξύ των stent struts, μπορούν να υποδαυλίσουν την νεοαθηροσκλήρυνση εντός του νέου έσω χιτώνα των κνημιαίων DES, η οποία μπορεί να οδηγήσει σε επαναστένωση εντός του stent (ISR) και απώλεια του εμβαδού του αυλού των περιφερικών αρτηριών. Οι παρατηρήσεις της μελέτης αυτής θέτουν σε αμφισβήτηση το παραδοσιακό τρόπο κατανόησης της περιφερειακής επαναστένωσης εντός του stent ως μιας απλής υπερπολλαπλασιαστικής απάντησης στο βαρότραυμα. Η απεικόνιση με FD-OCT είναι ένα βέλτιστο πειραματικό εργαλείο για την αξιολόγηση της εξέλιξης της αθηροσκληρωματικής νόσου και την επαναστένωση του αγγείου. Μπορεί να παρέχει υψηλής ευκρίνειας ενδοαγγειακή απεικόνιση κατά τη διάρκεια αγγειοπλαστικών επεμβάσεων στα κάτω άκρα και θα μπορούσε να αποδειχθεί κλινικά χρήσιμο για τον προσδιορισμό της εντός του stent πρόπτωσης ιστού και του strut malapposition. Παρ 'όλα αυτά, δεν πρέπει να χρησιμοποιηθεί ως εργαλείο για τη συνήθη κλινική πρακτική μέχρι να προκύψουν στοιχεία από περαιτέρω κλινικές δοκιμές για τον καθορισμό των ειδικών ενδείξεων της απεικόνισης με FD-OCT στις περιφερικές αρτηρίες. / Optical coherence tomography (OCT) is a catheter-based imaging method that employs near-infrared light to produce high-resolution intravascular images. OCT can readily visualize vessel microstructure at a 10- to 20-μm resolution with exquisite detail. To date, however, applicability of the method has been limited to small diameter arteries (≤4 mm). To the best of the author’s knowledge, this study is the first worldwide that demonstrates the safety and clinical feasibility of frequency domain Optical Coherence Tomography (FD-OCT) imaging of infrainguinal vessels in vivo during infrainguinal angioplasty procedures. It is also the first study that reports the use of intravascular FD-OCT to detect and characterize in-stent neointimal tissue following infrapopliteal drug eluting stent (DES) placement in patients suffering from critical limb ischemia. Quantitative lumen analysis of arteries with diameter up to 7 mm was performed. High-resolution OCT images provided exquisite two-dimensional axial and longitudinal views of the infrainguinal arteries and allowed thorough investigation of a variety of angioplasty sequela, including and not limited to intimal tears and dissection flaps, white and red thrombus, stent mesh malapposition, and intrastent plaque prolapse. Of interest, OCT identified cases of suboptimal postangioplasty outcome that single-plane subtraction angiography did not recognize and accounted. Mixed features of lipid pool areas, calcium deposits and calcified plaques, necrotic areas, and fibrosis were identified in all of the imaged atherosclerotic lesions. However, based on the predominant baseline imaging findings, lesions under investigation were classified as purely fibrotic, fibrocalcific, mostly lipid-laden and necrotic/calcified. Intraplaque accumulation of macrophages was noted in some of de novo atheromatic lesions. Varying degrees of neointimal hyperplasia were demonstrated in all cases of in stent restenosis (ISR) lesions with purely fibrotic features and considerable neovascularization in some of them. The latter finding coincided with the level of maximum vessel stenosis in all cases. Neoatherosclerosis following infrapopliteal DES placement is a frequent finding in both symptomatic and asymptomatic patients. Our preliminary observations allow us to speculate that analogous to coronary implanted DES, defective endothelialization induced by the eluted drug, along with neovascularization developing between the stent struts, may incite neointimal neoatherosclerosis, which may result in ISR and lumen loss of the peripheral arteries. It also seems that infrapopliteal neoatherosclerosis may be a significant contributing factor for ISR rather than a minor and sporadic process, highlighting the clinical significance of the phenomenon. Our observations put in dispute the traditional way of understanding peripheral in-stent restenosis as a simple hyperproliferative response to barotraumas and may explain the paramount importance of aggressive risk factor modification strategies. Neointimal neoatherosclerosis as identified by FD-OCT may have a role in the development of below-the-knee restenosis and thus warrants further investigation by larger controlled studies. Moreover, it may prove clinically useful for the determination of intrastent tissue prolapse and strut malapposition. FD-OCT should not be utilized as a tool for routine clinical practice until evidence from further clinical trials emerge to determine the specific indications for OCT imaging of the peripheral arteries.