Hybrid Approach to a Right Aortic Arch With a Large Kommerell's Diverticulum.

A 60-year-old woman with a family history of aortic dissection in her mother was investigated for dysphagia. Her scan showed a right aortic arch with a large Kommerell's diverticulum causing esophageal compression. Her left vertebral artery, which originated abnormally low in the thorax, was embolized preoperatively to limit operative difficulties. Two weeks later, a right thoracotomy allowed the resection of the aneurysm with an associated left carotid-axillary bypass. Partial cardiopulmonary bypass in moderate hypothermia with beating-heart perfusion of the brain was conducted. Five-year follow-up showed a favorable outcome. A multidisciplinary approach is a safe and simple strategy in complex cases.

Critical limb ischaemia and the response to bone marrow-derived cell therapy according to tcPO2 measurement.

BACKGROUND: Cell therapy is an emerging potential biotherapy for critical limb ischaemia (CLI) patients who are not eligible for revascularization. However, the findings on this technique's efficacy are inconsistent. Trials investigating this topic focused on the more severe CLI patients who were often beyond any therapy. Therefore, identifying those who may truly benefit from cell transplantation is now warranted. To this end, we studied the prognostic value of tcPO2 for major amputation after 1 year in patients treated with bone marrow-derived cells. PATIENTS AND METHODS: CLI patients ineligible for revascularization were included in a cell-therapy pilot study. On inclusion, patients underwent tcPO2 measurement in supine and sitting positions. For a tcPO2 < 10 mmHg in the supine position, the vascular reserve was defined by tcPO2 > 30 mmHg in the sitting position. Patients were administered intramuscular injections of mononuclear cells derived from aspirated bone marrow. RESULTS: In total, 25 patients (a lower limbs) were included for analysis. At inclusion, 11 lower limbs had tcPO2 at rest > 10 mmHg, and 16 lower limbs had a tcPO2 < 10 mmHg. The success probability for cell therapy was 0.79 (95 % CI 0.38-0.94) and 0.44 (95 % CI 0.18-0.67), respectively (p = 0.1). Of the 16 limbs with tcPO2 < 10 mmHg, the success rate was considerably higher in patients demonstrating a tcPO2 increase in a sitting position of over 30 mmHg (6/8, success probability 0.71, 95 % CI 0.26-0.92) compared to those without (2/8, success probability 0.15, 95 % CI 0.01-0.48, p = 0.03). CONCLUSIONS: For patients with chronic CLI for whom cellular therapy is a therapeutic option, a tcPO2 < 10 mmHg at rest, without vascular reserve (i. e. < 30 mmHg when sitting), is a prognostic indicator for poor outcome.
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Experimental study of sutureless vascular anastomosis with use of glued prosthesis in rabbits.

OBJECTIVE: The objective of this study is to explore the feasibility and efficacy of a new technique for sutureless vascular anastomosis, using glued prosthesis, as a sole anastomosis fixation method in rabbits. METHODS: Ten rabbits were randomly selected to conduct the experiment. Five rabbits underwent direct anastomosis of infrarenal abdominal aorta, with glued prosthesis. In five other rabbits, reconstruction was done by sutured anastomosis. All animals were immediately examined by echo-Doppler for patency of anastomosis. The burst pressure of the glued anastomosis was measured and compared with that of a sutured artery. The animals were euthanized, and tissue samples were taken for histological examination immediately after the experiment. RESULTS: Compared to conventional anastomoses, sutureless vascular anastomoses required shorter time of creation and significantly reduced blood loss (P<5%). There was no significant difference on the average blood flow through the anastomosis between two groups at the end of surgery. All anastomoses with glued prosthesis, examined by echo-Doppler, were patent at the anastomotic site, except one, which was stenosed immediately after surgery. In the control group, except one with stenosis, all conventional anastomoses were patent. Mean burst pressure at the anastomotic site for sutureless anastomoses was lower than in control group. Macroscopically, the BioGlue did not demonstrate any adhesion to the surrounding tissue as it was covered by the vascular prosthesis. Histological examination showed low-grade inflammatory reaction in glued anastomoses versus no inflammatory reaction at the sutured anastomoses. CONCLUSION: This technique may provide a feasible and successful alternative in vascular surgery. However, further long-term studies are necessary to elucidate the break pressure and degree of inflammation at the anastomotic site.

Vascular access-induced hand ischemia: risks and safe management.

Hand ischemia is rare but complex and multifactorial. Distal arteriopathy below the vascular access (VA) is responsible in the vast majority of patients and not a problem of high flow of the VA. Therefore, surgical technique should focus on improving blood flow and pressure instead of reducing blood flow. We present an overview of the standard techniques which are recommended to treat VA-induced hand ischemia. The banding techniques, most of which empirical and not codified, have been abandoned by the majority of the authors because of a high rate of failure and reintervention. Ligation may be necessary in patients with severe ischemia and diffuse arterial lesions and in case of ischemic monomelic neuropathy.

The vascular connector, design of a new device for sutureless vascular anastomosis.

BACKGROUND: In recent years, several methods and new techniques have been studied and proposed for establishment of sutureless vascular anastomoses, streaming use of sutureless vascular surgery in the future. PRESENTATION OF THE HYPOTHESIS: The new vascular connector (NVC) is a hypothetical design of a vascular device, proposed for creation and maintenance of sutureless vascular anastomosis. Implication of NVC would introduce a new device and technique in establishment of sutureless vascular anastomosis in which surgical approach is minimized and so post-operation disorders. It would eliminate need for suture; shorten clampage and operation time, consequently reducing stress for both, the surgeon and the patient. It enables the creation of vascular anastomosis fast, simple, safe, reliable, with satisfactory patency and stability of anastomosis. TESTING THE HYPOTHESIS: Efficacy of NVC needs to be evaluated in further studies, in order to be confirmed for clinical use. The effectiveness of NVC should be verified firstly in vitro and in vivo tests; and by animal experiments. The likelihood of its negative influence in thrombogenicity should be well evaluated. IMPLICATIONS OF THE HYPOTHESIS: Implication of the new vascular connector (NVC) would be of interest to both patients and the surgeon due to the following main achievements: 1) enables the creation of vascular anastomosis fast and simple, 2) significant shortening of clampage time of blood vessels and operation time-this assumption would be followed by reduced risk of operative and post-operative complications and length of hospital stay or admission to Intensive care unit, 3) safe and reliable, 4) compatible with any blood vessel and standard vascular graft, 5) using the NVC we will reduce in minimum need for replaced blood volume, 6) reduces the cost of treatment. It is anticipated that the NVC would provide shorter operation time and least operative and post-operative complications in creation of sutureless vascular anastomosis.

Mycotic aneurysm of the internal carotid artery.

BACKGROUND: Infected aneurysms of the extracranial carotid arteries are uncommon. This article presents a complete review of the literature on this condition, illustrated with a case report. This case report describes a mycotic aneurysm of carotid bifurcation with proven infection of the arterial wall from Salmonella enteritidis. The treatment consisted of excision of the aneurysm, ligation of the external carotid, and realization of a common to internal carotid artery bypass with the greater saphenous vein. METHODS: In August 2012, the authors searched the PubMed database with the keywords "carotid artery pseudoaneurysm" and "mycotic carotid aneurysm" for the period until 2012. RESULTS: The incidence of extracranial infected carotid artery aneurysm is relatively stable, with approximately 20 cases reported per decade over the past 30 years. The authors analyzed approximately 100 cases reported in the literature and studied the origin of the condition and the evolution of surgical options.

Endovascular treatment of aortic and primitive iliac artery aneurysms associated with Behçet disease.

Behçet disease is a systemic vasculitis that can cause vascular complications. We describe a 42-year-old woman with an aortic aneurysm and common right iliac aneurysm, both saccular and complicating Behçet disease. The patient was successfully treated by an endovascular method, which currently seems to be the best therapeutic choice given the frequent anastomotic complications of conventional surgical treatment.

Unusual foreign body in urinary bladder due to vascular surgery intervention.

Iatrogenic bladder injury in vascular surgery is very rare. We report a case of bladder injury by penetration secondary to the tunneling of a vascular graft through the space of Retzius. The diagnosis of an intravesical graft was made by computed tomography 1 week later. The patient underwent open bladder surgery associated with complete graft resection without immediate vascular reconstruction.

European Society of Hypertension scientific newsletter: hypertension and aortic diseases.

Hypertension, one of the major cardiovascular risk factors, promotes the formation of atheromatous lesions in the large arteries, including the aorta. It also favors aortic aneurysm and acute aortic syndrome such as aortic dissection or hematoma. In patients with aortic disease, beta-blockers and/or renin-angiotensin-aldosterone system inhibitors should be preferentially used to decrease blood pressure and improve arterial wall properties.

Three-year European follow-up of endovenous radiofrequency-powered segmental thermal ablation of the great saphenous vein with or without treatment of calf varicosities.

BACKGROUND: Radiofrequency segmental thermal ablation (RSTA) has become a commonly used technology for occlusion of incompetent great saphenous veins (GSVs). Midterm results and data on clinical parameters are still lacking. METHODS: A prospective multicenteral trial monitored 295 RSTA-treated GSVs for 36 months. Clinical control visits included flow and reflux analysis by duplex ultrasound imaging and assessment of clinical parameters according to the CEAP classification and Venous Clinical Severity Score (VCSS). RESULTS: A total of 256 of 295 treated GSVs (86.4%) were available for 36 months of follow-up. At 36 months, Kaplan-Meier survival analysis showed the probability of occlusion was 92.6% and the probability of no reflux was 95.7%, and 96.9% of legs remained free of clinically relevant axial reflux. If complete occlusion was present at the 12-month follow-up, the risk of developing new flow by 24 and 36 months of follow-up was 3.7% and 4.1%, respectively. Diameters of the GSV measured 3 cm distal to the saphenofemoral junction reduced from 5.8 ± 2.1 mm at screening to 2.2 ± 1.1 mm at 36 months. The average VCSS score improved from 3.9 ± 2.1 before treatment to 0.9 ± 1.5 at 3 months (P < .0001) and stayed at an average <1.0 during the complete 36 months of follow-up. Only 41.1% of patients were free of pain before treatment; at 36 months, 251 (98.0%) reported no pain and 245 (95.7%) did not experience pain during the 24 months before. At 36 months, 189 of 255 legs (74.1%) showed an improvement in CEAP class compared with the clinical assessment before treatment (P < .001). Stages C(3) and C(4) combined to 46% before treatment and dropped constantly to a combined level of 8% at 36 months. However, the proportion of C(2) legs that dropped from 52.3% before treatment to <10% at 12 months showed a constant increase thereafter, reaching 33.3% at 36 months. CONCLUSION: RSTA showed a high and durable success rate in vein ablation in conjunction with sustained clinical efficacy.

Radiofrequency-powered segmental thermal obliteration carried out with the ClosureFast procedure: results at 1 year.

This prospective and multicenter study shows the results at 1 year of radiofrequency-powered segmental thermal obliteration (RSTO) carried out with the ClosureFast procedure. The RSTO clinical and duplex ultrasound imaging results were evaluated at 3 days, 3 months, 6 months, and 1 year. All procedures were carried out on outpatients under tumescent local anesthesia. Among the 295 members who were treated, 289 were reexamined at 3 days, 290 at 3 months, 289 at 6 months, and 220 at 1 year. Occlusion scores were 99.7%, 99.3%, 98.6%, and 96.9% at, respectively, 3 days, 3 months, 6 months, and 1 year. At 3 cm below the saphenofemoral junction, before the procedure, the greater saphenous vein (GSV) diameter was 5.4+/-2 mm (range 2-18). It decreased to 4.5+/-1.7 mm at 3 days, 2.4+/-1.5 mm at 6 months, and 1.3+/-0.9 mm at 1 year. In members reexamined at 1 year, the decrease in diameter of the treated vein compared with the preprocedural measurement was 79% (p<0.001, t-test). At 1 year, in 58% of the cases, duplex ultrasound imaging at mid-thigh level could not show the GSV trunk. Preprocedural pain that was present in 57.5% of the cases decreased to 10.8% of the cases at 3 days and 2% of the cases at 1 year (p<0.001, chi2 test). Among the treated limbs, 70.1% did not present with any postprocedural pain at any time of the follow-up. On the third day, the patients evaluated the mean pain intensity at 0.7+/-1.6 on a visual analog scale of 0-10. During the follow-up, no painful indurations were noticed in 67.7% of the legs. No thromboembolic complications were reported. Paresthesias were observed in 3.4% of the cases. Invalidity clinical score, evaluated at 3.9+/-2 before the procedure, decreased to 3.5+/-1.2 on the third day, 0.9+/-1.5 at 3 months, 0.7+/-1.2 at 6 months, and 0.5+/-1.1 at 1 year. This study confirms the efficacy of RSTO when using ClosureFast, which allows obliteration of the GSV trunk in 97% of cases at 1 year with few side effects and almost no postprocedural pain.

Video-assisted removal of a ventricular mass through the mitral valve.

We report the case of 31-year-old man who was admitted for cerebellar ischemia. The echocardiography showed an intraventricular mass, mobile with the cardiac activity compatible with a thrombus or a myxoma. He successfully underwent a video-assisted removal of the mass, through the mitral valve.

Tracheoinnominate artery fistula: combined endovascular and surgical management by emergency stent-graft placement followed by cryopreserved arterial allograft repair.

Tracheoinnominate artery fistula is an uncommon but life-threatening complication usually requiring emergency ligation of the artery. The recent introduction of stent-grafts offers a new therapeutic option for emergency management of hemorrhage. Stent-grafts can be used for definitive treatment or as a bridge to surgery. The purpose of this report is to describe a case of hemoptysis due to a tracheoinnominate artery fistula that occurred after a single orotracheal intubation for general anesthesia and was treated by placement of a covered stent followed 12 hours later by surgical revascularization of the innominate artery using a cryopreserved arterial allograft.

Abdominal aortic aneurysm and Coxiella burnetii infection: report of three cases and review of the literature.

Coxiella burnetii, the etiologic agent of Q fever, is mainly responsible for endocarditis with negative blood culture results, but only a few cases of C. burnetii infections of aortic aneurysms have been published. We report three cases of abdominal aortic aneurysms treated in patients with Q fever infection with simultaneous endocarditis (n = 1) and previous history of cardiac valve replacement for endocarditis (n = 1). A coeliac aortic aneurysm was diagnosed in one patient treated for acute Q fever with persistent serologic results showing chronic infection despite adequate antibiotic therapy and without endocarditis. Resection of the aneurysm cured the chronic infection, and C. burnetii was identified by culture of the aneurysmal wall. In the two other cases, chronic infection of C. burnetii was diagnosed by serologic examination after surgery for an abdominal aortic aneurysm. One patient with negative blood culture results had amaurosis fugax due to endocarditis and required aortic valve replacement; recurrent fever without evidence of valve dysfunction or infection developed in one patient who had had prosthetic cardiac valve replacement 6 months earlier for endocarditis. Aortic aneurysms were treated with in situ prosthetic grafts and long-term antibiotic therapy. At a mean follow-up of 12 years, no septic aortic complications occurred, and serologic test results have remained negative. The presence of an aortic aneurysm and cardiac valve disease seems to be a predisposing factor for chronic C. burnetii infection. Diagnosis particularly relies on the physician's awareness of this condition and is confirmed by serologic examination. Aortic aneurysm resection is mandatory to cure the chronic infection and must be associated with long-term antibiotic therapy.

Esophageal fistula after endovascular treatment in a type B aortic dissection of the descending thoracic aorta.

We report a type B aortic dissection treated with stenting of the descending thoracic aorta that subsequently developed an ischemic necrosis of the esophagus with a posterior mediastinum abscess. The surgical treatment consisted of an extra-anatomic bypass to revascularize the supra-aortic trunks and the distal abdominal aorta through a middle sternal laparotomy, the resection of the thoracic aorta, and the drainage of the mediastinal abscess. Despite this aggressive surgical approach and an initial favorable postoperative course, the patient suddenly died 3 weeks later, likely from a rupture of the aortic stump.

Induction of tissue kallikrein in human carotid atheroma does not lead to kallikrein-kinins pathway activation.

OBJECTIVE: The impairment of the tissue kallikrein-kinin system (KKS) may result in atheroma development. To determine the involvement of KKS in pathophysiology of human atherosclerosis, we examined the expression of all components of this system as well as angiotensinogen (another tissue kallikrein (TK) substrate), at messenger ribonucleic acid (mRNA) and protein levels in the human carotid artery with and without atheroma. METHODS: mRNA levels were compared with semi-quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) between atheroma plaque and intact tissue obtained during carotid endarterectomy in 15 patients. The cellular localization of the transcripts and proteins was analyzed with in situ hybridization and immunohistochemistry. TK activity was measured using chromogenic substrate. RESULTS: The kininogen mRNA was not detected in carotid wall. The TK mRNA was increased four-fold and TK activity 23-fold in atheroma plaque compared with intact tissue. No difference was observed for B1, B2 receptors, kallistatin, angiotensinogen and protein-kinase G type 1alpha (PK-G) mRNAs. The TK and angiotensinogen transcripts as well as kininogen and angiotensinogen proteins were present in both intimal and medial cells. The kininogen immunoreactivity was weaker in atheroma. CONCLUSIONS: All KKS components were synthesized in arterial wall except kininogen probably coming from plasma. The absence of PK-G mRNA down-regulation in atheroma suggests that the kallikrein induction does not lead to KKS activation.

Treatment of hand ischemia following angioaccess surgery using the distal revascularization interval-ligation technique with preservation of vascular access: description of an 18-case series.

Hand ischemia is a rare complication of angioaccess surgery for hemodialysis. Management usually requires ligation of the arteriovenous fistula (AVF). The purpose of this report is to describe our experience with the use of the distal revascularization interval-ligation (DRIL) technique for treatment of ischemia without ligation of the AVF. From January 1999 to September 2002, the DRIL technique was used to treat 18 patients (10 men, 8 women, 10 diabetic patients) with severe paresthesia of the hand (n = 9) and finger necrosis (n = 10). The AVF was located at the elbow in 16 patients and at the wrist in 2 patients. Mean flow distal to the AVF was less than 10 mL in 5 patients, less than 5 mL in 10, and unmeasurable in 3. The conduit used for all DRIL arterial bypasses, including 15 brachiobrachial bypasses, 1 axillobrachial bypass, 1 brachioradial bypass, and 1 radioradial bypass, was the great saphenous vein graft. Trophic manifestations required finger amputation in five patients, pulpar necrosis resection in four, and transmetacarpal amputation of the index finger in one patient. Symptoms disappeared in 13 patients (73%) and improved in 5 (27%). The time required for healing of finger amputations and trophic manifestations ranged from 15 days to 2 months. Mean arterial flow through the DRIL bypass was 50 mL/min (range, 20-90 mL/min). With a mean follow-up interval of 16 months (range, 5-48 months), primary patency of the DRIL artery bypass and AVF was 94% and the limb salvage rate was 100%. The DRIL technique is the most effective procedure for treatment of angioaccess-induced hand ischemia. This technique can be used to achieve persistent relief of symptoms with continued access patency. The DRIL artery bypass improves vacularization of the hand, and ligature of the artery stops the vascular steal without affecting hemodialysis access. The DRIL technique should be proposed as first-line treatment for hand ischemia due to AVF for hemodialysis.

Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients.

Visceral artery aneurysms (VAA) can be treated by revascularization, ligation, or, most often, endovascular techniques depending on clinical presentation, hemodynamic status, and location. From 1975 to 2002 a total of 42 VAA in 34 patients were treated. The lesion involved the splenic artery (SA; 19), pancreaticoduodenal artery (PDA; 6), celiac trunk (CT; 5), superior mesenteric artery (SNA; 4), common hepatic artery (CHA; 3), gastroduodenal artery (GDA; 2), left hepatic artery (LHA; 1), a branch of the inferior mesenteric artery (BIMA; 1), and a branch of the SMA (BSMA; 1). Twenty-seven VAA in 21 patients (64%) were uncomplicated (group I) and 15 VAA in 13 patients (36%) had ruptured (group II) (PDA; 6; CT, 3; SA, 1; CHA, 1; LHA, 1; BSMA, 1; BIMA, 1). In group I VAA were treated by embolization (n = 11), splenectomy (n = 6), bypass (n = 7), ligation (n = 2), and aneurysmorraphy (n = 1). No deaths were observed. The morbidity rate associated with surgical treatment was 12% including hepatic bypass thrombosis without ischemic complications in two cases. The morbidity rate associated with endovascular treatment was 18% including cholecystitis in one case and bile duct stenosis in one case. The VAA recanalization rate following embolization was 9%. In group II, 12 VAA (80%) were treated by ligation in association with splenectomy in two cases and left hepatectomy in one case. Only one bypass procedure was performed and embolization was used to treat two VAA (1 SMA and 1 PDA). The mortality rate was 20% (3/15). The morbidity rate associated with surgical treatment was 46% (6/13) including bile duct stenosis in one case, ischemic cholecystitis in one case, duodenal fistula in one case, pancreatic fistula in one case, bile tract fistula in one case, and colonic ischemia in one case. No patient died after endovascular treatment and the morbidity rate was 50% (1/2) with duodenal stenosis occurring in one case. In sum, VAA can rupture. Emergency cases can be treated by ligation in most cases or by embolization if the hemodynamic status of the patient allows. Regardless of treatment technique, the morbidity and mortality rate remains high after rupture, especially in cases involving PDA. Embolization can be proposed as a first-line treatment for most VAA. Because of the risk of rupture, endovascular or open repair is warranted for VAA and has a favorable prognosis.

[Traumatic dissection of the renal pedicle. Modalities of management in adults and children]. / Dissection traumatique du pédicule rénal. Modalités de prise en charge chez l'adulte et l'enfant.

OBJECTIVE: To evaluate the medium-term results of treatment for traumatic dissection of the renal arteries in a series of 12 cases and to propose emergency management based on recent endovascular revascularization techniques. MATERIAL AND METHODS: Between January 1999 and July 2003, 12 patients were admitted for closed trauma of the renal artery. There were 11 dissections with thrombosis and 1 intimal flap without distal thrombosis. Six patients were revascularized surgically (3 reno-renal bypass grafts, 3 auto-transplantations), 4 patients were treated by an endovascular procedure and 2 patients were treated conservatively with simple surveillance. Renal function, renal artery patency and blood pressure were evaluated immediately and at 3 months by clinical examination, Doppler ultrasound of the renal artery or CT angiography, and renal scintigraphy. RESULTS: In the group of 6 patients undergoing surgical revascularization (mean warm ischaemia time: 8 hours 30 minutes), 2 nephrectomies were performed (1 failure of revascularization, 1 sepsis in a non-functioning kidney). The other 4 patients presented negligible renal function on scintigraphy at 3 months despite patent renal arteries. Among the 4 patients undergoing endovascular revascularization (mean warm ischaemia time: 8 hours 50 minutes), 2 died from associated lesions and 2 had a non-functioning kidney (1 stent thrombosis, 1 silent kidney despite a patent renal artery). No cases of hypertension were observed regardless of the type of management. CONCLUSION: Renal revascularization after thrombosis due to traumatic dissection of the renal artery must not be performed systematically after a warm ischaemia time of more than 4 hours in view of the poor recovery of renal function and the absence of morbidity associated with simple surveillance. When a procedure is performed, evaluation of the results must be based on morphological as well as functional parameters (scintigraphy).

Cathepsin G is associated with atheroma formation in human carotid artery.

OBJECTIVE: To elucidate the organization of the tissue angiotensin system, we investigated the expression and cellular localization of angiotensin system components and cathepsins D and G, potentially involved in intraparietal angiotensin II formation and atheroma. METHODS: Total RNA was extracted from atheroma plaque, fatty streaks and macroscopically intact tissue obtained during carotid endarterectomy in 21 hypertensive patients. mRNA levels were compared between these tissues using a semi-quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). In situ hybridization and immunohistochemistry were used to define the cellular localization of the transcripts and their respective proteins. RESULTS: Apart from renin and angiotensin type 2 (AT2) receptors, which were never detected, the studied mRNAs could be measured in all patients. Angiotensin-converting enzyme (ACE) mRNA was increased five-fold in atheroma, and angiotensin type 1 receptor (AT1) mRNA decreased 2.5-fold in atheroma and 1.4-fold in fatty streaks compared to intact tissue. A two-fold increase in cathepsin G mRNA was observed in atheroma plaque. In atheroma and intact tissue, significant positive correlations were found between cathepsin G and angiotensinogen, AT1 receptor and ACE mRNAs. Angiotensinogen and cathepsin mRNAs and proteins were detected in both arterial layers. AT1 immunoreactivity was mainly associated with alpha-actin-positive cells. CONCLUSION: All components required for angiotensin II formation are expressed locally in the arterial wall, where, in the absence of renin, cathepsin G could be a major angiotensin-generating enzyme. Overexpression of ACE and cathepsin G may lead to angiotensin II overproduction and contribute, with decreased number of differentiated smooth muscle cells, to the lower amount of AT1 receptor in atheroma.