Abstract-We asked whether balloon-injured neointima formation in the presence of high/low serum cholesterol (CT) levels might be affected by dietary supplementation with fish oil (FO). To test this hypothesis, we examined the differentiation, proliferation, or apoptosis profile of smooth muscle cell (SMC) and adventitial cell response to a mild injury induced via a Fogarty catheter in the carotid artery of adult rabbits that had been fed a standard chow or 0.5% CT-enriched diet starting 4 weeks before the lesion. One week before surgery, animals received FO supplementation. This regimen was continued for the following 3 weeks. The effect of FO on the early proliferative/migratory response of carotid SMCs was also examined in 2-and 7-day-injured normocholesterolemic rabbits. As controls, animals subjected to 3-week endothelial injury and animals kept on a 7-week CT diet were used. Carotid cryosections from the various animal groups were evaluated for morphometry (image analysis), differentiation (immunofluorescence with monoclonal antibodies specific for smooth muscle markers, ie, myosin isoforms, SM22, and fibronectin), proliferation (bromodeoxyuridine incorporation), and apoptosis (terminal deoxynucleotidyl transferase-mediated dUTP nick endlabeling). FO treatment significantly reduced the development of intimal thickening in normocholesterolemic rabbits but had no efficacy in the presence of relatively higher serum CT levels. At day 2 (adventitia) and day 7 (neointima, media, and adventitia), the proliferation index of SMCs in FO-treated injured rabbits was markedly lower than in untreated injured controls. Concomitantly with the antiproliferative effect, FO was able to decrease the size of 2 cell types involved in the cell growth response to endothelial injury, namely, the "fetal-type" medial SMC subpopulation and the fibroblast-derived adventitial myofibroblasts. Thus, in our experimental conditions, a low CT level is a permissive condition for FO to prevent neointima formation to a considerable extent. This event is attributable to the early postinjury effect of FO on SMC/adventitial cell proliferation/differentiation patterns. T he low occurrence rate of coronary heart disease in fish-consuming populations has raised the possibility that an increased consumption of the n ( )-3 polyunsaturated fatty acids (PUFAs) might be able to decrease the development of atherosclerosis in the vascular system. 1-5 Despite the expectancy raised by epidemiological studies, 3,5 contrasting results have been reported on the efficacy of FO as an antiatherogenic agent (in experimental animals 6 -17 ) and antirestenotic drug (in clinical trials 18 -26 ). The experimental studies published so far focused almost exclusively on the regressive capacity of PUFA/FO on atherosclerotic lesions in different models (rabbit, swine, nonhuman primates) and conditions (composition, dose, time of application, duration of PUFA/FO treatment, different ratio of polyunsaturated versus saturated fatty acids, isocaloric or nonisocaloric fatty aci...