**1. Introduction**

Ischemic cardiovascular disease (CVD) is the leading cause of death in worldwide and was responsible for approximately 17.8 million deaths in 2017 [1,2]. Additionally, it is estimated that current standard therapies are unsuitable or insufficient for 30% of patients [3,4]. Therefore, there is a critical need for new therapeutic treatments for ischemic CVD.

A potential strategy to treat patients with ischemia is to stimulate neovascularization, which is the body's natural repair mechanism to restore blood flow to ischemic tissues. Postnatal neovascularization is comprised of angiogenesis, the sprouting of new capillaries from existing vessels, and arteriogenesis, the maturation of preexisting collateral arterioles into fully functional arteries. Both angiogenesis and arteriogenesis are highly multifactorial processes that involve multiple types of vascular and immune cells. In order to improve neovascularization as a whole, therapeutic strategies which simultaneously target both angiogenesis and arteriogenesis are needed [5,6].

During the last decade, microRNAs have emerged as multifactorial regulators of neovascularization [7–9]. MicroRNAs are short non-coding RNAs of approximately 22 nucleotides that inhibit translation of messenger RNAs (mRNAs). A single microRNA can have hundreds of mRNAs in its 'targetome', often regulating an entire network or pathway simultaneously [10]. MicroRNAs are typically defined as one specific sequence of RNA nucleotides, however, recent studies have shown that this 'canonical' microRNA sequence is often altered. These microRNA alterations can be grouped into two types: (i) isomiRs, which are microRNAs with altered terminal sequences and (ii) biochemical modifications of specific nucleotides within microRNAs, which collectively are referred to as the microRNA epitranscriptome. Both types of microRNA variations appear actively regulated in response to ischemia and can directly influence neovascularization associated processes, as we will discuss below. The microRNA epitranscriptome unveils a whole new regulatory layer that could provide novel therapeutic options for ischemic CVD. In this review we will first briefly introduce the processes involved in angiogenesis and arteriogenesis, after which we will highlight various ways in which a microRNA can be altered, and discuss recent findings which demonstrate that these microRNA alterations can affect neovascularization associated processes.

#### **2. Neovascularization—Angiogenesis and Arteriogenesis**

After the occlusion of a large artery, blood flow to the downstream tissues is hampered, causing ischemia. Blood flow towards the ischemic tissue can be restored by a process called arteriogenesis. Arteriogenesis is the growth and maturation of collateral arteries from a pre-existing arteriole network, which connects all major arteries in the body [5]. Arteriogenesis is triggered by an increase in shear stress in the arterioles, which occurs after an arterial occlusion causes redirection of blood flow through the arterioles. The increased shear stress causes endothelial cells (ECs) in the arteriole wall to express adhesion molecules and secrete cytokines, leading to the attraction of circulating monocytes and other immune cells [11–15]. These inflammatory cells produce and secrete proteases, growth factors, and cytokines which enable remodeling of the vessel wall and stimulate migration and proliferation of vascular ECs and smooth muscle cells (SMCs) [16–18]. This results in an increase in vessel diameter, until fluid sheer stress decreases which halts the arteriogenic process. Finally, the vascular SMCs and fibroblasts secrete matrix components to reconstitute the vessel wall [19,20].

The process of angiogenesis, on the other hand, is the sprouting of a new capillary from the existing vasculature in order to redistribute local blood flow towards ischemic areas. Unlike arteriogenesis, angiogenesis is driven by the hypoxia caused by ischemia, and revolves around resolving local ischemia rather than restoring arterial blood flow after the occlusion of a vessel. Angiogenesis is initiated when an angiogenic stimulus, produced by hypoxic cells, activates the vascular endothelial layer. Activated ECs will start to proliferate and migrate towards the stimulus, such as vascular endothelial growth factor (VEGF), resulting in a new capillary [21]. Next to ECs, other cell types are important regulators of angiogenesis. Vascular SMCs, pericytes, fibroblasts and immune cells play key roles by supporting and modulating EC function and secreting the proangiogenic stimuli to start the process [22–24].

Since both angiogenesis and arteriogenesis are highly multifactorial processes, the simultaneous stimulation of both processes requires a multifactorial regulator, like microRNAs [7,8].
