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Environmental and genetic risk factors contribute to the etiology of abdominal aortic aneurysms (AAAs). Matrix metalloproteinases (MMPs) have been associated with the pathophysiology of AAAs. A prospective, nonrandomized case–control study was undertaken to investigate the risk factors for large AAAs (≥5.5 cm) among 175 male Greek AAA patients and to compare the results with a cohort of 166 male controls free from any aortic dilatation, as confirmed by ultrasonography from an existing AAA screening program in the same region. We also assessed the potential association between 2 functional single nucleotide polymorphisms in the genes MMP9 (−1561C/T; rs3918242) and MMP13 (−77A/G; rs2252070), and the presence of large AAAs. Multiple logistic regression analysis revealed AAA family history ( P = .028), hypercholesterolemia ( P < .001), and current smoking ( P < .001) as AAA risk factors. Statistical difference was reached in genotype ( P = .047) and allele ( P = .037) frequencies for rs2252070, but the results did not remain significant after correction for multiple testing. No significant differences in genotype or allele frequencies for rs3918242 were detected. In summary, AAA family history, hypercholesterolemia, and current smoking were found to be risk factors for large AAAs.

Hemodynamic changes occurring at the initial segments of the arterial bifurcations appear to play an important role in the development of atherosclerotic plaque. Therefore, arterial geometry might be a potential marker for atherosclerosis. Considerable evidence suggests that geometry can influence local hemodynamics at the carotid bifurcation contributing to the development of atheroma. Bifurcation angle, differences in the area ratios including the flare, proximal curvature, sinus bulb width, and tortuosity of the internal or external carotid artery have been listed as potential contributory elements. These morphometric details have been studied not only in postmortem examination but also with the help of imaging modalities such as ultrasound, digital subtraction angiography, computed tomography angiography, and the assistance of computational models and magnetic resonance angiography. The establishment of certain anatomical and geometrical details in addition to traditional risk factors may help in the identification of patients at high risk of developing carotid artery disease. We reviewed the literature to highlight the evidence on the importance of various geometrical details in the development of carotid atheroma and to suggest areas of future research.

A prospective nonrandomized cohort study on consecutive diabetic patients with foot ulcer was undertaken to assess the factors associated with the healing process or limb salvage and evaluate the impact of their treatment on their quality of life. Quality of life was evaluated using Diabetic Foot Ulcer Scale–Short Form (DFS-SF) questionnaire before and after treatment. A total of 103 diabetic patients with ulcer (mean age 69.7 ± 9.6 years, 77% male) were treated and followed up for 12 months. Ulcer healing, minor amputation, and major amputation rates were 41%, 41%, and 18%, respectively, while the mortality rate was 18%. Ulcer healing was associated with University of Texas wound grade 1 and the Study of Infections in Diabetic feet comparing Efficacy, Safety and Tolerability of Ertapenem versus Piperacillin/Tazobactam trial’s diabetic foot infection wound score. Limb loss was associated with nonpalpable popliteal artery, longer in-hospital stay, and delay until referral. Quality of life was improved in all domains of DFS-SF ( P < .0001) throughout the cohort of our patients regardless of their outcome, and no outcome (healing, minor amputation, or major amputation) was superior to other. Significant improvement was observed in all domains of hygiene self-management after consultation during the follow-up period.

We investigated the prevalence of peripheral arterial disease (PAD). Primary Care Health Centers (n = 14) in Thessaly (central Greece) recruited 436 participants, mean age 71 (50-79) years. Peripheral arterial disease was considered present if the ankle–brachial index (ABI) was 1.4 in at least 1 leg. Asymptomatic PAD was defined as an abnormal ABI and no symptoms or history of limb revascularization. The prevalence of PAD was 13% (mostly asymptomatic, 11.7%). Only 5 (8.77%) of 57 patients with PAD were aware of their disease and only in these patients were the physicians aware of the presence of PAD. The risk factors associated with PAD were age, smoking, and the combination of diabetes mellitus and coronary artery disease. All symptomatic patients were on antiplatelet therapy but 33% did not take statins. For asymptomatic patients, 74.5% were not on antiplatelet therapy and 57% did not receive statins. In the primary health care setting, PAD is underdiagnosed and undertreated.

Signorelli et al in this issue of Angiology screened almost 3500 asymptomatic individuals (mean age 61.3 + 9.7 years) using the ankle brachial index (ABI) to detect unrecognized peripheral arterial disease (PAD). An ABI 0.9 was considered diagnostic. A total of 80 (2.3%) participants had unrecognized PAD. Of interest, among those individuals with unrecognized PAD, 5% (n 1⁄4 4) also had >75% asymptomatic carotid artery stenosis, whereas 12.5% (n 1⁄4 8) had an ejection fraction 30% asymptomatic carotid artery stenosis. In multivariate analysis, an ABI 50% stenosis, whereas 2.7% had an occluded internal carotid artery. An ABI 3-fold increased risk for >50% carotid stenosis compared with individuals with an ABI >0.9 (odds ratio [OR], 3.37; 95% CI, 1.04-10.93; P 1⁄4 .033). An ABI

We assessed the effectiveness of iloprost treatment in the management of symptomatic Buerger disease (BD) and assessed smoking cessation compliance, based on a single-center experience. Thirteen patients with BD were treated with sessions of intravenous (IV) Ilomedin infusion. At 1-year follow-up, pain status alteration, number of analgesics required, ankle–brachial index (ABI) change, compliance with supervised smoking cessation, and amputation-free rate were recorded. The pain status improved considerably according to a visual analog scale, the number of analgesics required was significantly reduced, and all patients improved their pain-free walking distance, the ABI, and their self-reported quality of life. Only 2 patients required minor amputations. Combination of IV Ilomedin infusion, supervised smoking cessation, and a specific follow-up protocol may lead to improvement in pain-free walking distance, pain status, quality of life, and substantial reduction in amputation risk.

We reviewed the literature for studies investigating the outcomes of combined 1-stage coronary artery bypass grafting (CABG) and abdominal aortic aneurysm (AAA) open repair (OR) procedures. An electronic search of the English literature was conducted using the PubMed, EMBASE, and Cochrane databases. Age, coronary heart disease severity, AAA size, mean duration from CABG to AAA OR procedures, details of each procedure, mortality, and morbidity rates were analyzed. Between 1994 and 2012, 12 studies (256 patients) with 1-stage treatment fulfilled the inclusion criteria and were analyzed. There were 20 early (30 days) deaths, accounting for a 30-day mortality rate of 7.8%. The early morbidity was 53% (136 of 256). One-stage treatment when necessary can be undertaken with acceptable mortality and reasonable morbidity rates considering the complexity of both the operations. Nowadays, endovascular AAA repair is preferred over OR. The outcomes of combined cardiac surgery and endovascular AAA repair have not been extensively evaluated.

The first randomized study investigating the effect of aspirin on access patency rates was published almost 4 decades ago. This study showed a beneficial effect of aspirin treatment on early access thrombosis. More recently, a nonrandomized population-based study, the Dialysis Outcomes and Practice Patterns Study (DOPPS), evaluated the effect of aspirin and other drugs on primary and secondary vascular access patency rates in patients with AV fistulae (n 1⁄4 900) or AV grafts (n 1⁄4 1944). Aspirin treatment was associated with a 30% improvement in secondary AV graft patency (relative risk [RR], 0.70; P < .001). A single-center, nonrandomized study verified the beneficial effect of aspirin and ticlopidine on dialysisassociated platelet deposition in polytetrafluoroethylene grafts. Finally, an independent double-blind randomized study reported a beneficial effect of clopidogrel (n 1⁄4 46 patients) on primary AV fistula failure rates compared with placebo (n 1⁄4 47 patients; 5.2% vs 21.6%, respectively; P 1⁄4 .03). A daily dosage of clopidogrel 75 mg beginning 7 to 10 days prior to AV fistula creation was recommended to prevent AV fistula thrombosis and failure without increasing the risk of bleeding episodes. A multicenter, randomized, double-blind, placebo-controlled trial involving 877 patients with AV fistula compared the effects of 300 mg loading dose followed by 75 mg/d clopidogrel (n 1⁄4 441) versus placebo (n 1⁄4 436) on AV fistula thrombosis rates at 6 weeks. This trial was prematurely stopped due to the apparent superiority of clopidogrel versus placebo on AV fistula thrombosis rates (12.2% vs 19.5%, respectively; RR, 0.63; 95% confidence interval [CI], 0.46-0.97; P1⁄4 .018). Similarly, a multicenter (n1⁄4 9) prospective, randomized study, the Swedish Fistula Study Group reported a 35% (although nonsignificant) risk reduction for early AV fistula occlusion by ticlopidine treatment compared with placebo (occlusion rate: 12% vs 19%, respectively). The US Renal Data System Dialysis Mortality and Morbidity Wave II Study reported contradictory results. Treatment with the antiplatelet agents ticlopidine and dipyridamole (hazard ratio [HR], 3.54; 95% CI, 1.07-11.76; P 1⁄4 .04), or aspirin (HR, 2.49; 95% CI, 1.31-4.73; P 1⁄4 .005) was associated with worse AV fistula patency rates compared with nonuse in this retrospective cohort study. Consistent antiplatelet use is mandatory to obtain optimal results. The DOPPS showed that consistent aspirin use over 1 year after AV fistula creation was associated with a 37% lower risk of final AV fistula failure (adjusted HR, 0.63; 95% CI, 0.42-0.95, P 1⁄4 .03). The presence of oxidative stress and inflammation accelerates neointima formation and thrombosis. Aspirin not only acts as an antiplatelet agent but also reduces oxidative stress and inflammation. Importantly double antiplatelet treatment with clopidogrel plus aspirin is not indicated due to an increased risk of bleeding. In cases when double antiplatelet treatment is required, combination of aspirin with dipyridamole may improve patency rates without increasing the bleeding episodes. A Cochrane systematic review evaluated the effect of antiplatelet treatment on vascular access patency rates. This review included 3 randomized trials with aspirin and another 3 with ticlopidine. Both aspirin and ticlopidine increased vascular access patency rates compared with placebo (odds ratio [OR], 0.42; 95% CI, 0.20-0.86; P 1⁄4 .02; and OR, 0.47; 95% CI, 0.26-0.85; P 1⁄4 .01, for aspirin and ticlopidine

Ishibashi et al in this issue of Angiology assess the usefulness of serum cystatin C for predicting contrast-induced nephropathy (CIN) in patients undergoing coronary catheterization. Baseline serum cystatin C was both a predictor of CIN in patients with moderate renal insufficiency and a predictor of cardiac events after the occurrence of CIN. In the same issue, Shaker et al support that cystatin C and serum neutrophil gelatinaseassociated lipocalin may be early predictive biomarkers for CIN following percutaneous coronary angiography; both markers increase before serum creatinine (SCr) values following angiography. This editorial considers some additional aspects of CIN.

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).