This idea is related to the lipid infiltration hypothesis, 5 which originated with Anichkov and Khalatov 28 (reviewed in References 29 and 30 29, 30). Alterations in permeability or even microscopic losses of endothelial cells in excess of those due to normal cell turnover are not mechanistically required for atherogenesis, however, because normal, healthy endothelium transports 31, 32 or "leaks" 26, 33 many molecules, including lipoproteins (reviewed in Reference 27 27). In fact, the rate of LDL entry into the normal, healthy arterial wall vastly exceeds the LDL accumulation rate. 34 Most important, seminal studies by Schwenke and Carew 35, 36 showed in vivo that the early prelesional accumulation of atherogenic lipoproteins within the arterial wall is focally concentrated in sites that are known to be prone to the later development of atheromata, but that the rates of lipoprotein entry into prelesional susceptible versus resistant sites were not different (cf Reference 2 2). These studies indicate that retention, not enhanced endothelial permeability to lipoprotein influx, is the key pathological event in this experimental model. Subsequent studies in several other animal models have demonstrated either increased 23, 24, 25, 26 or decreased 37 rates of lipoprotein entry into atherosclerosis-susceptible sites, suggesting a nonessential role for alterations in endothelial permeability. All studies agree, however, that prelesional susceptible arterial sites show enhanced retention of apoB-rich, atherogenic lipoproteins. 35, 36, 38, 39, 40, 41 We conclude that alterations in endothelial permeability, though apparently not essential to lesion development, may play a contributory role, eg, in smoking, 42 dyslipidemias 27, 37 (cf Reference 36 36), and possibly hypertension 27 (cf Reference 43 43), but only if some of the infiltrated material is retained. 35 Several other functional modifications have been documented in the endothelial layer in vivo during atherogenesis, but these occur comparatively late. For example, in rabbits, cell adhesion molecules, 44 the earliest known being vascular cell adhesion molecule-1 (VCAM-1), are expressed by endothelial cells that overlie lesions, but only after more than 4 days of severe hypercholesterolemia and resultant foam cell formation. 45 In contrast, lipoprotein retention and aggregation are detectable within minutes to hours after the onset of hypercholesterolemia. 31, 36, 41, 46 Furthermore, atherogenic lipoproteins and their components have been shown to regulate endothelial expression of cell-adhesion molecules. 12, 47, 48, 49 The most straightforward conclusion is that the earliest known endothelial changes during atherogenesis in vivo, such as VCAM-1 expression, cannot be a cause, and are likely to be a consequence, of the initial retention of lipoproteins within the arterial wall (see "Future Directions").