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Background: Distal vessel quality is a key parameter in the global chronic total occlusion (CTO) crossing algorithm., Objectives: The study sought to evaluate the association of distal vessel quality with the outcomes of CTO percutaneous coronary intervention., Methods: We examined the clinical and angiographic characteristics and procedural outcomes of 10,028 CTO percutaneous coronary interventions performed at 39 U.S. and non-U.S. centers between 2012 and 2022. A poor-quality distal vessel was defined as <2 mm diameter or with significant diffuse atherosclerotic disease. In-hospital major adverse cardiac events (MACE) included death, myocardial infarction, urgent repeat target vessel revascularization, tamponade requiring pericardiocentesis or surgery, and stroke., Results: A total of 33% of all CTO lesions had poor-quality distal vessel. When compared with good-quality distal vessels, CTO lesions with a poor-quality distal vessel had higher J-CTO (Japanese chronic total occlusion) scores (2.7 ± 1.1 vs 2.2 ± 1.3; P < 0.01), lower technical (79.9% vs 86.9%; P < 0.01) and procedural (78.0% vs 86.8%; P < 0.01) success, and higher incidence of MACE (2.5% vs 1.7%; P < 0.01) and perforation (6.4% vs 3.7%; P < 0.01). A poor-quality distal vessel was independently associated with technical failure and MACE. Poor-quality distal vessels were associated with higher use of the retrograde approach (25.2% vs 14.9%; P < 0.01) and higher air kerma radiation dose (2.4 [IQR: 1.3-4.0] Gy vs 2.0 [IQR: 1.1-3.5] Gy; P < 0.01)., Conclusions: A poor-quality distal vessel in CTO lesions is associated with higher lesion complexity, higher need for retrograde crossing, lower technical and procedural success, higher incidence of MACE and coronary perforation, and higher radiation dose., Competing Interests: Funding Support and Author Disclosures The authors are grateful for the philanthropic support of the generous anonymous donors, and the philanthropic support of Drs Mary Ann and Donald A. Sens, Mrs. Diane and Dr Cline Hickok, Mrs Wilma and Mr Dale Johnson, the Mrs Charlotte and Mr Jerry Golinvaux Family Fund, the Roehl Family Foundation, and the Joseph Durda Foundation. The generous gifts of these donors to the Minneapolis Heart Institute Foundation and Center for Coronary Artery Disease helped support this research project. Dr Allana has served as a consultant for Boston Scientific Corporation. Dr Alaswad has served as a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems Inc. Dr Karmpaliotis has received honoraria from Boston Scientific, Abbott Vascular, and Abiomed; and owns equity in Saranas, Soundbite, and Traverse Vascular. Dr Jaffer has conducted sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, Boston Scientific, HeartFlow, and Amarin; has served as a consultant for Boston Scientific, Siemens, Magenta Medical, International Medical Device Solutions, Asahi Intecc, Biotronik, Philips, Intravascular Imaging, and DurVena; owns equity interest in Intravascular Imaging Inc and DurVena; and his employer, Massachusetts General Hospital, has licensing arrangements with Terumo, Canon, and Spectrawave, for which he has the right to receive royalties. Dr Khatri has received personal honoraria for proctoring and speaking for Abbott Vascular, Medtronic, Terumo, and Shockwave Medical. Dr Poommipanit has served as a consultant for Medtronic, Asahi Intecc, Abbott Vascular, and Boston Scientific. Dr Patel has received consulting honoraria from Abbott, Medtronic, Terumo, and Cardiovascular Systems. Dr Mahmud has served as a consultant for Abiomed, Medtronic, and Boston Scientific; and has served as chair for multiple Data, Safety and Monitoring Boards. Dr Nicholson has served as a proctor and on the Speakers Bureau and advisory board for Abbott Vascular, Boston Scientific, and Asahi Intecc; and owns reports intellectual property with Vascular Solutions. Dr Jaber received received research and educational funds from Medtronic, Inari Medical; has served as a consultant for Medtronic, Inari Medical; has received a proctoring fees from Abbott Vascular; and has served on the advisory board for Medtronic. Dr Rinfret has served as a consultant for Abbott Vascular, Abiomed, Boston Scientific Corporation, SoundBite Medical, and Teleflex. Dr Abi-Rafeh has served as a proctor for and received speaker honoraria from Boston Scientific and Abbott Vascular. Dr ElGuindy has received consulting honoraria from Medtronic, Boston Scientific, Asahi Intecc, and Abbott; proctorship fees from Medtronic, Boston Scientific, Asahi Intecc, and Terumo; and educational grants from Medtronic. Dr Sandoval has served on the advisory board for Roche Diagnostics and Abbott Diagnostics without personal compensation; and as a speaker without personal financial compensation for Abbott Diagnostics. Dr Burke has received consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, the American Heart Association (associate editor for Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; has received research support from Boston Scientific and GE Healthcare; is the owner of Hippocrates LLC; and is a shareholder for MHI Ventures, Cleerly Health, and Stallion Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with increased risk of periprocedural complications. Estimating the risk of complications facilitates risk-benefit assessment and procedural planning., Objectives: This study sought to develop risk scores for in-hospital major adverse cardiovascular events (MACE), mortality, pericardiocentesis, and acute myocardial infarction (MI) in patients undergoing CTO PCI., Methods: The study analyzed the PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) and created risk scores for MACE, mortality, pericardiocentesis, and acute MI. Logistic regression prediction modeling was used to identify independently associated variables, and models were internally validated with bootstrapping., Results: The incidence of periprocedural complications among 10,480 CTO PCIs was as follows: MACE 215 (2.05%), mortality 47 (0.45%), pericardiocentesis 83 (1.08%), and acute MI 66 (0.63%). The final model for MACE included ≥65 years of age (1 point), moderate-severe calcification (1 point), blunt stump (1 point), antegrade dissection and re-entry (ADR) (1 point), female (2 points), and retrograde (2 points); the final model for mortality included ≥65 years of age (1 point), left ventricular ejection fraction ≤45% (1 point), moderate-severe calcification (1 point), ADR (1 point), and retrograde (1 point); the final model for pericardiocentesis included ≥65 years of age (1 point), female (1 point), moderate-severe calcification (1 point), ADR (1 point), and retrograde (2 points); the final model for acute MI included prior coronary artery bypass graft surgery (1 point), atrial fibrillation (1 point), and blunt stump (1 point). The C-statistics of the models were 0.74, 0.80, 0.78, 0.72 for MACE, mortality, pericardiocentesis, and acute MI, respectively., Conclusions: The PROGRESS-CTO complication risk scores can facilitate estimation of the periprocedural complication risk in patients undergoing CTO PCI., Competing Interests: Funding Support and Author Disclosures The authors are grateful for the philanthropic support of our generous anonymous donors, and the philanthropic support of Drs. Mary Ann and Donald A. Sens, Mrs. Diane and Dr Cline Hickok, Mrs. Wilma and Mr. Dale Johnson, Mrs. Charlotte and Mr. Jerry Golinvaux Family Fund, the Roehl Family Foundation, and the Joseph Durda Foundation. The generous gifts of these donors to the Minneapolis Heart Institute Foundation's Science Center for Coronary Artery Disease helped support this research project. Dr Alaswad has served as a consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and CSI. Dr Davies has received honoraria from Boston Scientific, Medtronic, Siemens Healthineers, and Shockwave Medical. Dr ElGuindy has received consulting honoraria from Medtronic, Boston Scientific, Asahi Intecc, and Abbott; proctorship fees from Medtronic, Boston Scientific, Asahi Intecc, and Terumo; and educational grants from Medtronic. Dr Patel has received consulting honoraria from Abbott, Medtronic, Terumo, and Cardiovascular Systems. Dr Abi Rafeh has served as a CTO proctor and consultant for Boston Scientific and Abbott Vascular. Dr Karmpaliotis has received honoraria from Boston Scientific and Abbott Vascular; and owns equity in Saranas, Soundbite, and Traverse Vascular. Dr Khatri has received personal honoraria for proctoring and speaking from Abbott Vascular, Asahi Intecc, Terumo, and Boston Scientific. Dr Jaffer has performed sponsored research for Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific; has served as a consultant for Boston Scientific, Siemens, Magenta Medical, IMDS, Asahi Intecc, Biotronik, Philips, and Intravascular Imaging; owns equity interest in Intravascular Imaging and DurVena; and his employer (Massachusetts General Hospital) has licensing arrangements with Terumo, Canon, and Spectrawave, for which Dr Jaffer has right to receive royalties. Dr Doshi has served on the Speakers Bureau for Abbott Vascular, Boston Scientific, and Medtronic; and received research support from Biotronik. Dr Jaber has served on the advisory board for Medtronic; and received proctoring fees from Abbott Vascular. Dr Yeh has received grant or contract support from Abiomed, AstraZeneca, BD Bard, Boston Scientific, Cook Medical, Medtronic, and Philips; and consulting fees from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, and Shockwave Medical outside the submitted work. Dr Burke is a stockholder of MHI Ventures and Egg Medical. Dr Brilakis has received consulting or speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, the Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; has received research support from Boston Scientific, and GE Healthcare; is the owner of Hippocrates LLC; and is a shareholder of MHI Ventures, Cleerly Health, and Stallion Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Although the superiority of manual compression of the radial, mainly due to its selectivity and progressive grading, had been hypothesized from the early days of the transradial use, data on efficacy and safety of this method are only scarce. This review tries to delineate the aspects of manual hemostasis in transradial catheterization. Current data demonstrate that manual compression of the radial artery is a possible (second line) hemostatic option in transradial catheterization with main advantage the shorter hemostasis duration, and major disadvantage the need for larger involvement of post-procedural care team in hemostasis. Manual compression of the radial artery is a possible (second line) hemostatic option with main advantage the shorter hemostasis duration, and major disadvantages the need for larger involvement of post-procedural care team in hemostasis., Competing Interests: Declaration of competing interest None declared by all authors., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Transradial approach (TRA) for coronary angiography and interventions has been increasingly used over the last decades and has become the default strategy in the majority of catheterization laboratories worldwide. Recently, a novel transradial access site, the distal radial access (DRA), has been proposed as an alternative to traditional TRA. Several case reports and case series have been published on this new approach over the last year showing overall good success rates. Aim of this review is to present the possible benefits and drawbacks of DRA and offer guidance on its successful use., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate the efficacy and safety of distal radial (DR) versus traditional radial (TR) approach during coronary angiography., Methods: Two hundred patients scheduled to undergo transradial coronary angiography were randomized between the two approaches. Primary endpoint of the study was switching to another access site due to inability of successful target artery cannulation. Secondary endpoints were time to cannulation, total procedure duration, number of attempts, number of skin punctures and duration of manual hemostasis. Secondary safety endpoints were the rate of moderate or severe spasm, arm hematoma EASY class III or more and radial artery occlusion at discharge. Quality of life endpoint was the patient's preference of cannulation method at 30 days., Results: The primary endpoint was met in 30 patients (30%) from the DR group and 2 patients (2%) from the TR group (p < 0.001). The time of cannulation was longer in the DR group compared to the TR group (269 ± 251 s vs 140 ± 161 s, p < 0.001), but this did not affect the total procedural duration (925 ± 896 s vs 831 ± 424 s, p = 0.494). The number of attempts and the number of skin punctures were more in the DR group compared to the TR group (6.8 ± 6.2 vs 3.4 ± 4.5, p < 0.001 and 2.4 ± 1.7 vs 1.6 ± 1.2, p < 0.001, respectively). However, DR treated patients had faster manual hemostasis time compared to TR treated patients (568 ± 462 s vs 841 ± 574 s, p = 0.002). There were no differences recorded in the safety endpoints of moderate or severe spasm, EASY grade III or more radial hematomas or the incidence of radial artery occlusion after the procedure. Patients' preference to the randomized puncture sites was the same (79% vs 85%, p = 0.358)., Conclusion: Distal radial approach is associated with lower successful cannulation rates and shorter manual hemostasis time compared to the traditional radial approach., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The aim of this article is to focus on the utilization of forearm approach for cardiac catheterization in challenging groups of patients. Radial and ulnar approaches have gained significant popularity among the majority of interventional cardiologists. Multiple studies have demonstrated the feasibility, safety and efficacy of forearm route for cardiac catheterization and have highlighted the significant reduction in bleeding complications by avoiding the puncture of the groin. In this review we present the strategies need to be followed in order to apply the forearm approach in challenging group of patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to compare manual versus mechanical compression of the radial artery after coronary angiography via transradial access regarding radial artery occlusion (RAO), access-site bleeding complications, and duration of hemostasis., Background: Hemostasis of the radial artery after sheath removal can be achieved either by manual compression at the puncture site or by using a mechanical hemostasis device. Because mechanical compression exerts a more stable, continuous pressure on the artery, it could be hypothesized that it is more effective compared with manual compression regarding hemostasis time, bleeding, and RAO risks., Methods: A total of 589 patients undergoing diagnostic coronary angiography by transradial access with a 5-F sheath were randomized in a 1:1 ratio to receive either manual or mechanical patent hemostasis of the radial artery. Radial artery patency was evaluated by color duplex ultrasonography 24 h after the procedure. The primary endpoint was early RAO at 24 h. Secondary endpoints included access-site bleeding complications and duration of hemostasis., Results: Thirty-six (12%) early RAOs occurred in the manual group, and 24 (8%) occurred in the mechanical group (p = 0.176). There were no significant differences between the 2 groups regarding access-site bleeding complications (hematoma, 52 [17%] vs. 50 [18%]; p = 0.749; bleedings, 8 [3%] vs. 9 [3%]; p = 1.000). Duration of hemostasis was significantly shorter in the manual group (22 ± 34 min vs. 119 ± 72 min with mechanical compression; p < 0.001)., Conclusions: Manual and mechanical compression resulted in similar rates of early RAO, although the total duration of hemostasis was significantly shorter in the manual group., (Copyright © 2018 American College of Cardiology Foundation. All rights reserved.)

Balloon uncrossable lesions are a well-known challenge during chronic total occlusion (CTO) interventions. The technique of using two different catheters into the same coronary artery, the so-called "ping-pong" technique, is a technique described for treating complications during percutaneous coronary intervention (PCI), like perforations or rotational atherectomy burr entrapment. We describe a case where the "ping-pong" technique was successfully used to facilitate treatment of a balloon uncrossable CTO lesion., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the efficacy of radial artery cannulation with needle versus cannula over needle during transradial coronary angiography and intervention., Methods: Five hundred patients scheduled to undergo transradial catheterization were randomized between the two methods. Primary endpoint of the study was the combined endpoint of switching to another access site due to inability of successful sheath insertion or switching to another method of cannulation (from needle to cannula over needle and vice versa)., Results: The primary end point was met in 12 patients (4.8%) from the needle group and 14 patients (5.6%) from the cannula over needle group (p=0.695). There were no differences in switching of cannulation method [10 (4.0%)% versus 11 (4.4%), p=0.831], switching of access site [6 (2.8%) versus 9 (3.6%), p=0.441), time for artery cannulation [1.20 (0.80-2.20) min versus 1.26 (1.01-2.39) min, p=0.152], total procedure time [15.05 (9.47-29.03) min versus 19.14 (10.13-32.02) min, p=0.112] number of attempts [2 (1-4) versus 2 (1-5), p=0.244] and number of skin punctures [1 (1-2) versus 1 (1-2), p=0.399] before successful radial artery cannulation. There were no differences recorded in the safety endpoints of EASY grade III or more radial hematomas [2 (0.8%) versus 1 (0.4%), p=1.000] or the incidence of radial artery occlusion after the procedure [9 (3.6% versus 16 (6.8%), p=0.358]., Conclusion: Radial artery cannulation with needle and cannula over needle seems to be equal in terms of efficacy and safety., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Forearm approach for coronary catheterization is associated with better outcomes, compared to the femoral approach. However, the possibility of post catheterization forearm artery occlusion is a medical concern, which leads many patients to be treated transfemorally. We present a case series of patients who had a harvested radial artery and were successfully catheterized from ipsilateral ulnar artery without any complications recorded., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: We sought to assess the feasibility and safety of same-day discharge (SDD) after complex percutaneous coronary intervention (PCI) using a forearm approach., Background: SDD has been shown to be safe after elective, low-risk PCI. However, the feasibility and safety of SDD in more complex patients and lesions has received limited study., Methods: We retrospectively reviewed 1190 elective PCIs that were performed between January 2013 and December 2015 at the Red Cross General Hospital., Results: Of the 1190 PCIs, 166 (13.9%) were complex (bifurcations, vein and arterial grafts, unprotected left main, last remaining vessel, chronic total occlusions, or with utilization of rotational atherectomy or hemodynamic support). As compared with non-complex cases, complex cases were associated with older age, male gender, higher prevalence of diabetes mellitus and prior coronary artery bypass graft surgery, lower prevalence of smoking, higher utilization of femoral access and 7F guiding catheters, higher contrast utilization and fluoroscopy dose, longer fluoroscopy time, more stents per lesion, more frequent single vessel treatment and non-complete revascularization, and treatment with ticagrelor and bivalirudin. Among the patients who underwent complex PCI (n=166), twenty eight (16.9%) were discharged the same day. SDD after complex PCI was associated with younger age and more frequent use of forearm access. The 30-day incidence of major adverse cardiac events after complex PCI was 0% vs 3.6% (p=0.59) in patients with SDD vs. overnight hospitalization., Conclusions: SDD is feasible and safe in selected patients undergoing elective complex PCI using the forearm approach., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Endovascular aortic aneurysm repair (EVAR) and transfemoral transcatheter aortic valve replacement (TAVR) are widely spreading minimally invasive procedures performed mainly through the femoral artery. Prostar XL and ProGlide vascular closure devices are used in clinical practice for the hemostasis in these procedures and they have been shown to be safe and effective., Purpose: The aim of our systematic review is to compare the safety of these two devices for percutaneous closure of large arteriotomies in patients undergoing TAVR and EVAR., Methods: We searched PubMed, EMBASE, Google Scholar and the Cochrane Central Register of Controlled Trials for all randomized and observational published studies that compared Prostar XL vs. ProGlide. Relative risk was calculated by random-effects model. Review Manager 5.1 was used for statistical analysis., Results: A total number of 2909 patients were included in our analysis. The rate of overall vascular complications did not differ between Prostar XL and ProGlide {RR 1.35 (0.80-2.29), p=0.27}. In contrary, the risk ratio of all bleeding complications with Prostar XL compared to ProGlide was 1.82 (1.47-2.24, p<0.001) and for major and life-threatening bleeding complications was 2.48 (1.65-3.73, p<0001, suggesting a lower bleeding risk with ProGlide). No statistical difference was found between groups for end-stage acute kidney injury (AKI), with a risk ratio of 2.14 (0.81-5.66), p=0.05. Finally, there were no differences in in-hospital and 30-days mortality rate between the two groups (1.41, 0.56-3.54, p=0.46 and 1.43, 0.55-3.73, p=0.47, respectively)., Conclusions: Prostar XL is associated with greater risk of any bleeding as well as life threatening bleeding compared to the ProGlide device. However, no significant differences were observed in the rate of overall vascular complications, end stage AKI and in-hospital and 30-days mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Coronary stent delivery can be extremely challenging in tortuous and calcified lesions especially when radial approach is chosen. Guide extension catheter is a useful tool for overcoming the inherent difficulties arising by the use of radial access in complex percutaneous interventions. We describe a technique for guide extension catheter system advancement by presenting two cases. This was performed stepwise by repeated distal balloon anchoring in the coronary artery of interest., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The transradial approach is associated with fewer bleeding complications during percutaneous coronary interventions (PCIs) but is more technically challenging and associated with prolonged times during intervention. The aim of this study is to retrospectively compare the results of radial vs. femoral approach in patients >or=80 years old undergoing primary or rescue PCI., Methods: Between January 2002 and December 2007, 354 interventions were performed in our institution with the indication of primary or rescue PCI in patients over 80 years old, without history of previous bypass operation or cardiogenic shock on presentation. Thirteen patients required a change of the approach during the procedure and were not enrolled in the final analysis. Forty (12%) interventions were performed through the transradial approach and 301 (88%) through the femoral approach. In-hospital major adverse cerebral and cardiac events and access site bleeding complications as well as 30- and 365-day mortality, procedural times, and contrast volume were evaluated., Results: The two groups had similar clinical characteristics, with the exception of serum creatinine that was higher in the transfemoral approach group. There were no differences in procedural times and clinical outcomes, although the transfemoral group had numerically more access site bleeding complications (12/301 vs. 0/40, P=.41). The transradial approach had a higher conversion rate compared with the transfemoral approach (18.3% vs. 1.3%, P<.001)., Conclusion: The transradial approach is feasible and safe in the octogenarians undergoing primary and rescue PCI, but it is associated with a high conversion rate to another approach.

Background: Treatment with statins is considered a first line therapy in atherosclerotic disease. Intraplaque angiogenesis is involved in plaque progression and instability. It remains unclear whether the beneficial effect of statin treatment in humans is achieved through reduced intraplaque angiogenesis. The aim of this study was to evaluate the capillaries density in carotid plaques removed from patients treated with statin versus untreated patients., Methods and Results: We studied 102 patients who underwent carotid endarterectomy: 98 of them met the inclusion criteria and entered the study; 75 men and 23 women; mean age 66+/-8 years (range 42-83 years). Forty-three patients (44%) were on statin treatment at least 3 months before endarterectomy and 55 (56%) had never received statin treatment. The intensity of intraplaque angiogenesis was evaluated with immunohistochemistry using the antibody CD34. The number of capillaries per mm(2) was measured with a custom designed image tool analysis. With the exception of serum total cholesterol levels and serum low-density cholesterol levels, the two groups of patients did not vary significantly in cardiovascular risk factors and in parameters pertaining to the procedure profile. Patients on statin treatment had less capillaries per mm(2) than patients not receiving this kind of drugs (0.97+/-0.61 per mm(2) versus 1.39+/-0.98 per mm(2), p=0.031). Univariate associations between possible explanatory variables and number of capillaries per mm(2) were tested using Spearman rank R. Variables associated with a p-value <0.20 (age, serum creatinine, serum total cholesterol, serum low-density lipoprotein, serum homocysteine, presence of diabetes mellitus and statin treatment) were entered in a multivariable model. Multivariate analysis showed that statin treatment was the only independent predictor (t=-5.39, p<0.001) of intraplaque angiogenesis., Conclusions: Statin therapy is associated with reduced intraplaque angiogenesis in the carotid arteries. This could provide an explanation for the beneficial effects of this kind of drug on patients with atherosclerotic disease.