针刺法作用兔血管再狭窄模型的病理学研究

目的:探讨针刺作用动脉再狭窄的病理学改变,为针刺临床治疗冠状动脉成形术后再狭窄提供理论依据.方法:应用PTCA球囊导管对实验兔行双侧髂动脉内膜剥脱建立动脉粥样硬化模型术后,狭窄者再行PTCA球囊扩张术以建立再狭窄模型,动物组织进行HE染色,观察针刺后髂动脉,冠状动脉及主动脉内膜的形态学变化.结果:针刺组主动脉、髂动脉及冠状动脉脂斑面积与模型组差异不显(P＞0.05);内膜增生程度均较轻,内膜中VSMC、泡沫细胞较少;动脉内膜及中膜面积与模型组差异明显(P＜0.01).结论:针刺法对动脉血管再狭窄具有一定的防治作用.     

Doxy对大鼠动脉内膜损伤后MMP-1表达影响的研究

目的:观察动脉内膜损伤后基质金属蛋白酶-1(MMP-1)的表达变化,探讨Doxy和MM-1对动脉内膜损伤后再狭窄的影响.方法:建立大鼠颈总动脉损伤模型,治疗组用多西环素30mg·kg-1·d-1干预,免疫组化测定损伤动脉中MMP-1的表达,弹力纠维染色观察损伤动脉内膜面积、管腔面积的情况.结果:①MMP-1阳性指数于损伤后3d表达最高,以后逐渐减少,28d时达最低值,Doxy治疗组MMP-1表达的阳性指数3d,7d,14d均低于手术组(P＜0.01),而28d则与手术组无明显差别(P＞0.05).②内膜面积自术后7 d开始增加,28d后达最高值,管腔面积自术后7 d开始减少,28d后达最低值.Doxy治疗组14 d及28 d内膜面积明显小于手术组,管腔面积明显大于手术组,具有显著差异(P＜0.01).结论:动脉内膜损伤后MMP-1强烈表达,Doxy可以显著降低血管损伤后前2周MMP-1的表达,提示它可能防治动脉内膜损伤后再狭窄而不需长期给药.     

血管内皮生长因子基因对兔髂动脉内膜损伤的组织形态变化过程的影响

探讨血管内皮细胞的特异丝裂原－血管内皮生长因子（VEGF）基因阻止血管内膜损伤后形成再狭窄的组织变化过程。建立球囊拉伤血管内膜的兔髂动脉模型,将携带VEGF目的基因的真核表达载体pcDNA3/VEGF经多聚赖氨酸处理的PTCA球囊导管导入拉伤的血管内膜。VEGF基因组拉伤2周时血管内壁有VEGF mRNA和蛋白的高表达。血管内膜内皮化较快。2周时即有许多血管内皮细胞呈岛状分布。4周时内膜基本恢复光滑。内膜平滑肌细胞增生明显减少,而对照组2周时血管内膜粗糙,基底膜暴露,拉伤后4周仍无内皮细胞再生,最后形成虫蚀样改变。血管中膜平滑肌细胞穿过内弹性膜进入内膜并大量增生,内膜增厚。VEGF基因定位导入血管内壁后。VEGF mRNA和蛋白高表达且发挥其生物学效应,内皮细胞岛状增生,加快内膜内皮化,减轻内膜增厚。     

Egr-1的诱骗性寡脱氧核苷酸抑制大鼠颈总动脉损伤后MMP-2的表达

目的观察局部转染早期生长反应因子-1(early growth response factor-1,Egr-1)的特异诱骗寡脱氧核苷酸(decoy oligodeoxynucleotides,decoy ODNs)对球囊损伤颈总动脉后基质金属蛋白酶-2(MMP-2)蛋白表达的影响及内膜增生的情况,初步探讨Egr-1,decoy ODNs抑制球囊损伤后内膜增生的机制。方法 96只健康雄性Wistar大鼠,随机分为4组,分别为假手术组、对照组、杂码组和诱骗组,每组24只。除假手术组外均应用2F球囊导管行颈总动脉球囊损伤术,术中采用转染试剂FuGENE6介导的Egr-1decoy ODNs转染至损伤后大鼠血管中,与假手术组、对照组、杂码组相比较。术后3、7、14、21d每组处死6只动物。应用HE染色和免疫组织化学方法观察大鼠颈总动脉球囊损伤后内膜增生情况和MMP-2蛋白的表达及转染Egr-1decoy ODNs后对它们的影响。结果 (1)、内膜损伤后3d内膜增厚不明显,7d内膜开始增厚,14、21d时内膜明显增厚。(2)、在假手术组近腔面中膜可见MMP-2有少量散在阳性表达;在对照组及杂码组动脉损伤后3d,在近腔面中膜,有少量阳性表达,与假手术组相比,阳性表达指数上升。7d时在新生内膜和靠近新生内膜处中膜表达明显,14d后表达逐渐下降。(3)转染decoy ODNs治疗后,在各个时间点内膜增厚程度减轻,MMP-2蛋白表达减少,与对照组比较差异有显著性(P<0.01)。结论血管球囊损伤后,内膜7d开始增生,14d、21d增生更明显,而MMP-2在7d时表达明显,之后逐渐下降,Egr-1decoy ODNs能抑制MMP-2的表达,从而减轻血管损伤后内膜的增生。     

AT2R载体可调控表达对大鼠颈动脉损伤后骨桥蛋白及新生内膜增生的影响

目的:血管紧张素Ⅱ 2型受体(AT2R)基因转染的骨髓间充质干细胞(MSC)在四环素可调控系统下作为载体,利用计算机图像分析系统研究新生内膜增生的情况,并探讨AT2R在体可调控表达对大鼠颈动脉损伤后骨桥蛋白(OPN)表达影响。方法:利用球囊损伤60只SD大鼠颈动脉,并随机将SD大鼠分为5组,分别为正常组(未行球囊扩张术)、对照组(球囊扩张术后注入PBS)、MSC组(球囊扩张术后注入常规MSC)、MSC转染组(球囊扩张术注入转染AT2R的MSC)、强力霉素(Dox)组(球囊扩张术后注入转染AT2R的MSC,术后当天至处死前三天通过尾静脉注射Dox 100μg/kg/d)。术后14及28天分别处死大鼠取材,光镜下观察血管内膜增生情况,Image pro plus 6.0计算机图像分析系统测量新生内膜面积(I/M),逆转录-多聚酶链反应(RT-PCR)检测AT2R及OPN在大鼠血管标本中的表达变化。结果:大鼠颈动脉AT2R在Dox组的表达显著增高,新的增生内膜面积较其它各损伤组显著降低(P≤0.01),并且OPN的表达显著低于其他各手术组。结论:AT2R基因在体可调控表达受到Dox的有效控制,AT2R基因可能抑制血管损伤后OPN的表达及新生内膜的过度增生。     

Simvastatin 与rhG-CSF 促进兔颈总动脉球囊损伤后内膜修复 的实验研究

目的:观察辛伐他汀及重组人粒细胞集落刺激因子(rhG-CSF)在兔颈总动脉内膜损伤后对血管壁变化及外周血中CD34+细胞含量的影响。方法:雄性新西兰大白兔48只,随机均分为:单纯损伤组,辛伐他汀组,rhG-CSF组及辛伐他汀和rhG-CSF联合组(简称联合组),建立兔左颈总动脉内膜球囊导管损伤模型,术后给予辛伐他汀(10mg/kg/d经胃灌入)及rhG-CSF(100μg/d皮下注射)干预治疗,每组分别于术前1d、术后7d、14d、21d、28d抽取静脉血2ml,经流式细胞仪检测外周血中CD34+细胞含量;4周后处死所有动物取损伤段血管,弹力纤维染色,计算内膜厚度、中膜厚度、管腔面积(S)、内膜面积(Si)、中膜面积(Sm)及Si/Sm比值评价血管再狭窄程度。结果:①术前4组之间相比外周血CD34+细胞含量无明显差异(P>0.05);术后7d时各组外周血CD34+细胞含量最高,后逐渐下降,28d较低,但仍高于术前含量;rhG-CSF组及联合组与对照组相比外周血CD34+细胞明显增多(P<0.01,P<0.01);术后7d、14天时辛伐他汀组与单纯损伤组相比外周血CD34+细胞无明显差别(P>0.05)。术后21d、28天时辛伐他汀组与单纯损伤组相比外周血CD34+细胞有显著差异(P<0.05)。②与单纯损伤组相比辛伐他汀组、rhG-CSF组及联合组Si/Sm比值明显减小(P<0.05);辛伐他汀组和rhG-CSF组两组间比较无显著差别(P>0.05);联合组分别与辛伐他汀组、rhG-CSF组比较血管内膜增生更少,具有显著性(P<0.01,P<0.01)。结论:本实验研究发现辛伐他汀可促进损伤内膜修复及预防血管再狭窄,长期服用可以增加外周血CD34+细胞;rhG-CSF可明显增加外周血CD34+细胞及预防血管在狭窄;辛伐他汀与rhG-CSF联合用药可明显增加外周血CD34+细胞、加速内皮修复与预防再狭窄,较单一用药具有更好的疗效。     

囊肿去顶减压术是否改善肾功能的动物实验研究

目的:通过模型加压兔子肾脏,监测加压前后肾功能变化,论证压力对肾功能的影响,根据实验结果给多囊肾临床治疗提供借鉴。方法:将成年新西兰兔随机分为三组(A,B,C),A组兔子切除一侧肾脏,另一侧肾脏通过模型固定圆形气泡予肾脏加压;B组兔子切除一侧肾脏,另一侧肾脏通过模型固定塑料圆球予肾脏加压;C组兔子切除一侧肾脏,另一侧肾脏不予加压处理。分别监测实验组和对照组兔子术前术后肾功的变化(血肌酐、尿素)。对不同加压肾脏标本进行HE、masson和六氨银染色,了解肾脏加压后的病理改变。结果:实验组A行加压术后肾功相对术前与对照组C相比无明显差异;实验组B行加压术后,肌酐、尿素升高明显,与术前、实验组A、对照组C比较均有明显差异(P<0.01)。实验组C一侧肾切除后相比术前肾功能无明显差异。病理示:肾脏加压后,肾小球、肾小管、肾血管继发一系列损害肾功的病理改变。结论:对肾脏施加的压力足够大的时候,压力致使肾脏发生相应病理改变,肌酐、尿素升高,肾功能明显下降。因此传统的囊肿去顶减压术,仍是有意义的对症治疗手段。     

凝血酶调节蛋白基因防治血管内膜增生狭窄的实验研究

目的:观察凝血酶调节蛋白(Thrombomodulin,TM)基因转染兔髂动脉损伤模型后,对动脉血管内膜增生狭窄的防治作用。方法:用注射式加压转染的方式对兔动脉壁转染pcDNA3.1/hTM质粒,再制造动脉损伤-阻滞模型,于术后3天、7天、14天、28天用免疫组化的方法观察TM蛋白在各组血管腔内的表达,术后14天、28天用彩色多普勒观察活体吻合口内径和血流流速;再做病理切片Verhoeff染色,观察血管内膜增生的程度、部位,计算血管内膜面积、中膜面积和血管狭窄率。结果:术后3天、7天、14天、28天hTM质粒转染组中hTM表达一直保持在高水平,7天达到高峰,14天、28天虽有所下降但是表达强度仍然高于载体质粒转染组合空白对照组。在术后14天、28天彩色多普勒观察测量吻合口内径:hTM质粒转染组分别为1.93mm±0.34mm,1.89mm±0.28mm;载体质粒转染组为1.59mm±0.43mm,1.38mm±0.28mm;空白对照组1.46mm±0.25mm,1.44mm±0.32mm。在这两个时间点,hTM质粒转染组血管狭窄率为32±23%,37±14%;载体质粒转染组为58±21%,63±17%;空白对照组为58±19%,61±23%。结论:hTM基因在转染动脉壁后能减少动脉损伤-阻滞模型在后期的血管内膜增生,改善血管的狭窄状况。     

兔颈动、静脉移植桥血管狭窄模型的建立及其电镜观察

目的:建立兔颈动、静脉移植血管桥动物模型,观察移植桥血管内膜增生和狭窄的电镜下表现。方法:通过兔双侧颈动脉进行动脉桥和静脉桥的移植,形成双侧移植血管桥再狭窄动物模型。在第8周施行血管桥移植手术的同时留取右侧颈动静脉标本作为对照血管,再分别于第12周、16周和第20周分别处死模型兔,采集移植桥血管标本,在光镜下测量其内膜厚度、面积、狭窄度,并进行电镜观察。结果:颈动脉和颈静脉桥移植后,随着时间的延长,桥血管的出现平滑肌迁移,脂质沉积,内膜增生,血管狭窄等改变,且以静脉桥血管的病理改变更为明显。结论:在兔形成动脉粥样硬化病变基础上,进行双侧颈动脉血管桥的移植,建立兔双侧颈动脉移植血管桥再狭窄动物模型,有利于设立自身对照,研究术后动静脉桥再狭窄差异机制;建立动、静脉桥后,位于血管中膜的平滑肌细胞出现向血管内膜迁移现象,说明中膜平滑肌细胞迁移进入内膜导致新内膜形成是血管再狭窄的重要环节。     

E1A激活基因阻遏子基因表达变化与颈动脉血管重塑的关系

E1A激活基因阻遏子(CREG)是一种广泛表达的小分子糖蛋白,但其生物学功能仍不完全清楚.为了探索病理性血管重塑的病理生理机制以及CREG在其中发挥的调控作用,采用颈动脉导丝损伤模型构建小鼠病理性血管重塑模型,应用小动物超声、Masson染色、免疫组织化学染色、RT-PCR、Western-blot等方法检测小鼠颈动脉内膜-中膜厚度、胶原含量、Ⅰ型胶原和CREG表达变化.结果表明,小鼠颈动脉损伤后3 d血管壁CREG m RNA和蛋白质水平迅速下降,损伤后7 d CREG表达回升,至损伤后14 d和28 d基本恢复到正常对照组水平.血管损伤后3 d血管壁中Ⅰ型胶原m RNA水平开始升高,损伤后7 d血管壁开始增厚,管壁中Ⅰ型胶原表达水平继续增高,损伤后14 d和28 d新生内膜形成,管腔严重狭窄,Ⅰ型胶原在管壁和新生内膜内大量表达.血管损伤早期CREG表达水平的变化与病理性血管重塑程度呈负相关关系,CREG的表达为先迅速降低,再逐渐回升,而胶原表达和血管重塑程度则表现为持续加重.上述研究结果提示,CREG基因表达参与血管损伤导致的病理性血管重塑过程,并可能决定了血管重塑的进程和结局.     

17-AAG对大鼠颈总动脉球囊损伤后内膜增生的影响及其作用机制

目的:研究17-丙烯胺-17去甲氧格尔德霉素(17-Allylamino-17-emethoxy-geldanamycin, 17-AAG)对球囊损伤后大鼠颈总动脉内膜增生的影响及可能作用机制。方法:将清洁级雄性SD大鼠36只按照随机数字法分为假手术组(Sham组)12只、球囊损伤组(Balloon injury, BI组)12只及17-AAG治疗组(17-AAG组)12只。采用2F Fogarty球囊建立大鼠颈总动脉球囊损伤组模型,17-AAG治疗组大鼠在建模后腹腔注射17-AGG(20 mg/kg 2d)。各组大鼠于球囊损伤3周后取损伤段颈总动脉,通过HE染色观察血管内膜形态学改变并评估内膜增生情况,免疫组化染色(Immunohistochemical staining,IHS)法检测血管壁增殖细胞核抗原(Proliferating cell nuclear antigen,PCNA)的表达,评估血管平滑肌细胞的增殖情况。流式细胞术检测血管平滑肌细胞的凋亡情况。结果:BI组、17-AAG组大鼠球囊损伤后颈总动脉内膜出现不同程度增生,内膜/中膜面积比(Intima area/Membrane area,I/M)均较Sham组显著升高(P0.05);17-AAG组的I/M较BI组明显下降(P0.05)。BI组、17-AAG组颈总动脉PCNA表达水平较Sham组明显升高(P0.05),较BI组显著降低(P0.05)。BI组、17-AAG组大鼠血管平滑肌细胞凋亡率较Sham组显著升高(P0.05);17-AAG组大鼠血管平滑肌细胞凋亡程度较BI组明显升高(P0.05)。结论:17-AAG对球囊损伤后颈总动脉内膜增生存在抑制作用,其机制可能是通过提高血管平滑肌细胞凋亡率影响其增殖程度。     

Perivascular gene transfer of dominant-negative N19RhoA attenuates neointimal formation via inhibition of TGF-β1-Smad2 signaling in rats after carotid artery balloon injury

Phenotypic differentiation of adventitial fibroblasts to myofibroblasts is an essential feature of vascular remodeling. Here, we carried out perivascular gene transfer of dominant-negative N19RhoA to investigate whether antagonism of RhoA signaling attenuates neointimal formation following rat carotid artery balloon injury and alters TGF-β1-Smad2-induced differentiation of adventitial fibroblasts to myofibroblasts. Perivascular delivery of an adenovirus coexpressing dominant-negative N19RhoA and humanized Renilla green fluorescent protein (hrGFP) (Ad-N19RhoA-hrGFP), as demonstrated by hrGFP staining, suppressed neointimal formation at 7 and 14 days post-injury. Ad-N19RhoA-hrGFP administration inhibited neointimal α-smooth muscle-actin and Calponin expression, as markers of myofibroblast differentiation and perivascular collagen deposition, at 14 days after balloon injury. Ad-N19RhoA-hrGFP administration also inhibited adventitial Smad2 phosphorylation, but did not alter local TGF-β1 and total-Smad2 expression after injury. Our results provide evidence that perivascular gene transfer of dominant-negative N19RhoA blocks TGF-β1-Smad2-induced differentiation of adventitial fibroblasts to myofibroblasts, which contributes to intimal hyperplasia after balloon injury.     

Balloon injury does not induce heme oxygenase-1 expression, but administration of hemin inhibits neointimal formation in balloon-injured rat carotid artery.

It has been shown that antioxidant agents act inhibitorily against neointimal formation after balloon injury, suggesting the role of oxidative stress as a promotor of intimal cell proliferation. Heme oxygenase-1 (HO-1) is an inducible form of heme catabolizing enzyme that is induced by and acts against oxidative tissue injury. In this set of experiments, we showed that HO-1 was present in newly formed neointima; however, arterial HO-1 expression did not increase in response to balloon injury in rat carotid artery. Intraperitoneal administration of hemin, a HO-1 inducer, for 5 consecutive days resulted in about a 4-fold increase of serum bilirubin concentration. In addition, hemin injection increased HO-1 protein expression in the carotid artery, the heart, the kidney, and the liver. In this condition, balloon injury-induced neointimal formation was markedly inhibited. Local application of tin protoporphyrin, a HO inhibitor, blocked this effect, suggesting that induced HO-1 in the carotid artery was responsible for the inhibition of neointimal formation after balloon injury. This study suggests that induction of the endogenous antioxidant gene can suppress neointimal formation after balloon injury.     

Detection of bone marrow-derived cells in neointimal thickening in the rat carotid artery by nested polymerase chain reaction

The bone marrow origin of cells involved in neointimal formation after injury of the luminal surface of the vessel was confirmed by highly sensitive nested polymerase chain reaction on isolated vascular wall cells. The model of intimal hyperplasia after balloon angioplasty of the carotid artery in radiation bone marrow chimeras between male and female Wistar rats was used. The Y chromosomes of rat male donors of the bone marrow for irradiated females were used as a marker of bone marrow-derived cells. This approach demonstrated a bone marrow origin of a large fraction of α-actin-positive (smooth muscle) neointimal cells.     

Carotid artery ligation induced intimal thickening and proliferation is unaffected by ageing

Following interventions to treat atherosclerosis, such as coronary artery bypass graft surgery, restenosis occurs in approximately 40% of patients. Identification of proteins regulating intimal thickening could represent targets to prevent restenosis. Our group previously demonstrated that in a murine model of vascular occlusion, Wnt4 protein expression and β-catenin signalling was upregulated which promoted vascular smooth muscle cell (VSMC) proliferation and intimal thickening. In this study, the effect of age on VSMC proliferation, intimal hyperplasia and Wnt4 expression was investigated. In vitro proliferation of VSMCs isolated from young (2 month) or old (18–20 month) C57BL6/J mice was assessed by immunocytochemistry for EdU incorporation. As previously reported, 400 ng/mL recombinant Wnt4 protein increased proliferation of VSMCs from young mice. However, this response was absent in VSMCs from old mice. As our group previously reported reduced intimal hyperplasia in Wnt4^+/? mice compared to wildtype controls, we hypothesised that impaired Wnt4 signalling with age may result in reduced neointimal formation. To investigate this, carotid artery ligation was performed in young and old mice and neointimal area was assessed 21 days later. Surprisingly, neointimal area and percentage lumen occlusion were not significantly affected by age. Furthermore, neointimal cell density and proliferation were also unchanged. These data suggest that although Wnt4-mediated proliferation was impaired with age in primary VSMCs, carotid artery ligation induced neointimal formation and proliferation were unchanged in old mice. These results imply that Wnt4-mediated proliferation is unaffected by age in vivo, suggesting that therapeutic Wnt4 inhibition could inhibit restenosis in patients of all ages.     

Effect of resveratrol on intimal hyperplasia after endothelial denudation in an experimental rabbit model

The ability of resveratrol to inhibit vascular intimal thickening was tested in an experimental model in which endothelial denudation was performed in the normal rabbit iliac artery. Resveratrol (2 approximately 4mg/ kg/d) was administered intragastrically for 5 weeks beginning 1 week before denudation. At the higher concentration of resveratrol, the intimal hyperplasia of injured vascular wall was effectively inhibited; the intimal proliferation index also was significantly less than that in the untreated control group (0.28 +/- 0.07 vs 0.41 +/- 0.13, respectively, p<0.01); the relative luminal area increased from 0.38 +/- 0.06 in the untreated control group to 0.53 +/- 0.10 in the resveratrol treatment group (p < 0.001); and the count of smooth muscle cells in the thickened intima was statistically significantly reduced in the high dose resveratrol treatment group than that in the untreated group (1,115 +/- 510 vs 1,796 +/- 963, respectively, p < 0.05). Resveratrol added to the culture media of cultured rabbit vascular smooth muscle cells inhibited DNA synthesis in a dose-dependent manner. These results showing that resveratrol is capable of inhibiting intimal hyperplasia of injured artery raise the possibility that this polyphenol might have clinical potential in prevention and treatment of restenosis after angioplasty.     

The kinase inhibitor fasudil (HA-1077) reduces intimal hyperplasia through inhibiting migration and enhancing cell loss of vascular smooth muscle cells.

Smooth muscle cell (SMC) migration plays an important role in restenosis after angioplasty. Myosin phosphorylation is necessary for cell migration. Fasudil is an inhibitor of protein kinases, including myosin light chain kinase and Rho associated kinase, thereby inhibiting myosin phosphorylation, and it has been clinically used to prevent vasospasm following subarachnoid hemorrage. Based on these findings, we examined the anti-migrative action of fasudil. In SMC (SM-3), fasudil (1-100 microM) inhibited SMC migration in a dose-dependent manner (p < 0.001). Fasudil suppressed actin stress fiber formation dose dependently. In rabbit carotid artery, fasudil (10 mg/kg/day) markedly reduced intimal hyperplasia 14 days following balloon injury. Cell kinetic study showed that fasudil did not affect proliferation but enhanced cell loss in the media after injury. We concluded that fasudil reduced neointimal formation after balloon injury through both inhibiting migration and enhancing cell loss of medial SMC.     

Involvement of altered arginase activity, arginase I expression and NO production in accelerated intimal hyperplasia following cigarette smoke extract

In the present experiments, we tried to elucidate whether changes in arginase activity, protein expression of arginase-I and -II, and NO production are involved in accelerating the intimal hyperplasia following administration of cigarette smoke extract (CSE). The intimal hyperplasia was caused by removing endothelial cells with the aid of balloon embolectomy catheter in the right carotid artery of the male rabbit. The left carotid artery underwent sham operation and served as control. CSE was prepared by bubbling a stream of cigarette smoke into phosphate buffered saline. Rabbits were given subcutaneously with CSE once a day for 5 weeks from 1 week before to 4 weeks after the surgery. The specimens were assessed histologically and the intima/media ratio (%) was evaluated as an index of the intimal hyperplasia. The accelerated intimal hyperplasia with CSE was accompanied by the augmentation of the impaired cyclic GMP production, enhanced overall arginase activity and up-regulation of arginase-I. Pearson's correlation coefficient analyses revealed the close relationships among the arginase activities in endothelial cells and smooth muscle layer, the intimal/media ratio and cyclic GMP production. These results suggest that the enhanced arginase activity together with facilitated up-regulation of arginase-I with CSE, which was associated with the augmented impairment of NO production, shed a new light on the processes associated with accelerating the intimal hyperplasia in rabbit carotid arteries following CSE.