Shichita et al in this issue of Angiology compare the angiographic characteristics of radiation-induced carotid artery stenosis with those of nonirradiated, atherosclerotic carotid stenosis. All established risk factors for carotid artery disease (ie, smoking, hypertension, diabetes mellitus, and hyperlipidemia) tended to be less frequent in the radiotherapy compared with the atherosclerotic group. Despite that, the radiation-induced carotid lesions were longer than the nonirradiated atherosclerotic carotid lesions (27.7 + 13.3 vs. 15.9 + 9.5 mm, respectively; P < .01). The conclusion reached is that local radiotherapy is as strong a risk factor for carotid artery stenosis as the established vascular risk factors. This Editorial deals with some additional issues regarding irradiation-induced carotid artery stenosis. The effect of radiation on normal tissues has been investigated since the early 1940s when the widespread use of irradiation therapy began. In 1942, Warren presented a detailed discussion of the irradiation-induced changes on the cardiovascular system; the similarity of radiation-induced changes in the vessel lumen with the atherosclerotic plaques in arteries was noted in this early report. The similarity of irradiation-induced plaque-like intimal thickening with arterial changes occurring during the atherosclerotic process was also reported by others. Animal work suggested that elevated serum cholesterol and hyperlipidemia may contribute to the development of radiation-induced carotid artery stenosis. A high-cholesterol diet induces early atheromatous changes; the addition of irradiation at even low dosage accelerates this effect. The association between hypercholesterolemia/hyperlipidemia and a faster progression of irradiation-induced carotid atherosclerosis was reported in humans three decades ago. Nine patients with irradiation-induced documented carotid stenosis were compared with 40 patients having carotid artery disease without previous history of neck irradiation. The irradiated group was younger and had less peripheral vascular and coronary heart disease but an increased incidence of localized carotid artery disease. It was proposed that elevated serum cholesterol and hyperlipidemia contribute to the development of radiation-induced carotid artery stenosis. Extrapolation from the results of the above studies suggested that irradiated carotid arteries are more susceptible to hypercholesterolemia. Therefore, even normal blood cholesterol levels may be harmful for these patients. Aggressive blood cholesterol lowering should thus be initiated at the time of neck irradiation (if not before). Statins comprise an essential component in the management of vascular From the Department of Vascular Surgery, Red Cross Hospital, Athens, Greece (KIP); Department of Vascular Surgery, University Hospital of Larissa, University of Thessaly Medical School, Larissa, Greece (ADG); Department of Clinical Biochemistry (Vascular Disease Prevention Clinic), Royal Free Hospital Campus, University College Medical School, University College London (UCL), London, UK (DPM).