High-Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes.

OBJECTIVES: High-need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes. DESIGN: Latent class analysis was used to identify phenotypes within a sample of HN fee-for-service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post-acute assessment data. SETTING: Not applicable. PARTICIPANTS: Two cross-sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643). MEASUREMENTS: The following variables were used to identify phenotypes: acute and post-acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes. RESULTS: Five phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4. CONCLUSIONS: Our findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70-77, 2019.

Near-Sun observations of an F-corona decrease and K-corona fine structure.

Remote observations of the solar photospheric light scattered by electrons (the K-corona) and dust (the F-corona or zodiacal light) have been made from the ground during eclipses1 and from space at distances as small as 0.3 astronomical units2-5 to the Sun. Previous observations6-8 of dust scattering have not confirmed the existence of the theoretically predicted dust-free zone near the Sun9-11. The transient nature of the corona has been well characterized for large events, but questions still remain (for example, about the initiation of the corona12 and the production of solar energetic particles13) and for small events even its structure is uncertain14. Here we report imaging of the solar corona15 during the first two perihelion passes (0.16-0.25 astronomical units) of the Parker Solar Probe spacecraft13, each lasting ten days. The view from these distances is qualitatively similar to the historical views from ground and space, but there are some notable differences. At short elongations, we observe a decrease in the intensity of the F-coronal intensity, which is suggestive of the long-sought dust free zone9-11. We also resolve the fine-scale plasma structure of very small eruptions, which are frequently ejected from the Sun. These take two forms: the frequently observed magnetic flux ropes12,16 and the predicted, but not yet observed, magnetic islands17,18 arising from the tearing-mode instability in the current sheet. Our observations of the coronal streamer evolution confirm the large-scale topology of the solar corona, but also reveal that, as recently predicted19, streamers are composed of yet smaller substreamers channelling continual density fluctuations at all visible scales.

Reserve and Alzheimer's disease genetic risk: Effects on hospitalization and mortality.

INTRODUCTION: Cognitive reserve predicts delayed diagnosis of Alzheimer's disease (AD) and faster postdiagnosis decline. The net impact of cognitive reserve, combining both prediagnosis and postdiagnosis risk, on adverse AD-related outcomes is unknown. We adopted a novel approach, using AD genetic risk scores (AD-GRS), to evaluate this. METHODS: Using 242,959 UK Biobank participants age 56+ years, we evaluated whether cognitive reserve (operationalized as education) modified associations between AD-GRS and mortality or hospitalization (total count, fall-related, and urinary tract infection-related). RESULTS: AD-GRS predicted mortality and hospitalization outcomes. Education did not modify AD-GRS effects on mortality, but had a nonsignificantly (interaction P = .10) worse effect on hospitalizations due to urinary tract infection or falls among low education (OR = 1.07 [95% CI: 1.02, 1.12]) than high education (OR = 1.01 [0.95, 1.07]) individuals. DISCUSSION: Education did not convey differential survival advantages to individuals with higher genetic risk of AD, but may reduce hospitalization risk associated with AD genetic risk.

Systematic review with meta-analysis: recurrence of hepatocellular carcinoma following direct-acting antiviral therapy.

BACKGROUND: Although studies suggest decreased incident hepatocellular carcinoma (HCC) after direct-acting antivirals (DAA), data are conflicting regarding HCC recurrence and aggressiveness in patients who have a history of HCC with complete response. AIM: Characterize HCC recurrence patterns after DAA therapy. METHODS: Two reviewers searched MEDLINE and SCOPUS from January 2015 to December 2017 and identified studies evaluating HCC recurrence patterns following DAA therapy. A pooled estimate was calculated using the DerSimonian and Laird method for a random effects model. The study was conducted in accordance with PRISMA guidelines. RESULTS: Among 24 studies (n = 1820 patients), the proportion of patients with HCC recurrence following DAA therapy ranged from 0% to 59% (pooled estimate 24.4%; 95% CI: 18.4%-30.4%). Among 11 full text manuscripts, pooled HCC recurrence was 21.9% (95% CI: 16.2%-28.3%). Factors associated with recurrence included history of prior HCC recurrence and a shorter interval between HCC complete response and DAA initiation. Nine studies comparing DAA-treated and interferon-treated or untreated patients found similar recurrence among DAA-treated patients. Most (77.8%) patients with HCC recurrence were detected at an early tumour stage, of whom 64.7% received curative treatment. Study limitations included heterogeneous cohorts, potential misclassification of HCC absence prior to DAA, ascertainment bias for recurrence, and short durations of follow-up. CONCLUSIONS: Current data suggest acceptable HCC recurrence rates after DAA therapy, particularly if DAA therapy is delayed at least 6 months after HCC complete response. However, data characterising HCC recurrence after DAA therapy are of limited quality, highlighting the need for high quality prospective studies.

Pain characteristics associated with the onset of disability in older adults: the maintenance of balance, independent living, intellect, and zest in the Elderly Boston Study.

OBJECTIVES: To determine the effects of chronic pain on the development of disability and decline in physical performance over time in older adults. DESIGN: Longitudinal cohort study with 18 months of follow-up. SETTING: Urban and suburban communities. PARTICIPANTS: Community-dwelling older adults aged 65 and older (N = 634). MEASUREMENTS: Chronic pain assessment consisted of musculoskeletal pain locations and pain severity and pain interference according to the subscales of the Brief Pain Inventory. Disability was self-reported as any difficulty in mobility and basic and instrumental activities of daily living (ADLs, IADLs). Mobility performance was measured using the Short Physical Performance Battery (SPPB). Relationships between baseline pain and incident disability in 18 months were determined using risk ratios (RRs) from multivariable Poisson regression models. RESULTS: Almost 65% of participants reported chronic musculoskeletal pain at baseline. New onset of mobility difficulty at 18 months was strongly associated with baseline pain distribution: 7% (no sites), 18% (1 site), 24% (multisite), and 39% (widespread pain, P-value for trend < .001). Similar graded effects were found for other disability measures. Elderly adults with multisite or widespread pain had at a risk of onset of mobility difficulty at least three times as great as that of their peers without pain after adjusting for disability risk factors (multisite pain: risk ratio (RR) = 2.95, 95% confidence interval (CI) 1.58-5.50; widespread pain: RR = 3.57, 95% CI = 1.71-7.48). Widespread pain contributed to decline in mobility performance (1-point decline in SPPB, RR = 1.47, 95% CI = 1.08-2.01). Similar associations were found for baseline pain interference predicting subsequent mobility decline and ADL and IADL disability. Weaker and less-consistent associations were observed with pain severity. CONCLUSION: Older community-dwelling adults living with chronic pain in multiple musculoskeletal locations have a substantially greater risk for developing disability over time and for clinically meaningful decline in mobility performance than those without pain.

Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study.

OBJECTIVES: To examine whether overall depressive symptoms and symptom clusters are associated with fall risk and to determine whether chronic pain mediates the relationship between depression and fall risk in aging. DESIGN: Prospective cohort study. SETTING: Boston, Massachusetts, and surrounding communities. PARTICIPANTS: Older community-dwelling adults (N = 722, mean age 78.3). MEASUREMENTS: Depressive symptomatology was assessed at baseline using the 20-item Hopkins Revision of the Center for Epidemiologic Studies Depression Scale (CESDR) as overall depression and two separate domains: cognitive and somatic symptoms. Chronic pain was examined at baseline as number of pain sites (none, single site, or multisite), pain severity, and pain interference with activities of daily living. Participants recorded falls on monthly postcards during a subsequent 18-month period. RESULTS: According to negative binomial regression, the rate of incident falls was highest in those with the highest burden of depressive symptoms (according to total CESDR and the cognitive and somatic CESDR domains). After adjustment for multiple confounders and fall risk factors, fall rate ratios comparing the highest three CESDR quartiles with the lowest quartile were 1.91, 1.26, and 1.11, respectively. Similarly graded associations were observed according to the CESDR domains. Although pain location and interference were mediators of the relationship between depression and falls, adjustment for pain reduced fall risk estimates only modestly. There was no interaction between depression and pain in relation to fall risk. CONCLUSION: Depressive symptoms are associated with fall risk in older adults and are mediated in part by chronic pain. Research is needed to determine effective strategies for reducing fall risk and related injuries in older people with pain and depressive symptoms.

Mental health and exposure to patient distress among families of nursing home residents with advanced dementia.

CONTEXT: The effect of suffering among patients with advanced dementia on their family members' mental health has not been investigated. OBJECTIVES: To describe family members' exposure to distressing symptoms among nursing home (NH) residents with advanced dementia and associations between such exposure and family members' mental health. METHODS: Data were obtained from an 18-month prospective cohort study of NH residents with advanced dementia and their family member health care proxies (HCPs). Exposure to resident symptoms and associated fear and helplessness was measured quarterly using the Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) scale (range 0-120). HCP mental health was assessed quarterly using the Composite International Diagnostic Interview Short Form (CIDI-SF) (depression), K6 (psychological distress, range 0-24), and SF-12(®) mental health subscale. RESULTS: Seven hundred seventy-nine SCARED scale assessments were completed by 225 HCPs. The most frequent distressing symptoms were the following: feeling the resident had had enough (33.2%), choking (21.1%), and pain (18.9%). The symptoms eliciting the greatest fear were thinking the resident was dead and seeing them choke. A sense of helplessness was highest when the resident was observed to be in pain or choking. Family members with SCARED scores >0 were more likely to meet criteria for depression on the CIDI-SF (adjusted odds ratio [AOR] 2.59, 95% confidence interval [CI] 1.14, 5.85), have a K6 score >0 (AOR 2.31, 95% CI 1.55, 3.43), and have lower SF-12 scores (adjusted parameter estimate -1.51, 95% CI -2.56, -0.47). CONCLUSION: Family member exposure to distressing symptoms experienced by their loved ones with advanced dementia is not uncommon and is associated with worse mental health.

Vein patch angioplasty with non-penetrating titanium clips. Comparison to standard suture technique.

Our purpose was to compare the Vascular Closure Staples (VCS) clips to a standard suture technique for vein patch angioplasty in a porcine model. Six female pigs underwent vein patch angioplasty of the common iliac arteries with either VCS clips or continuous suturing. The reconstructed vessels were evaluated macroscopically, angiographically and histologically after two months by re-operation. There was a non significant trend towards shorter reconstruction (6.5 +/- 1.8 min. for clips vs. 8.5 +/- 1.7 min. for sutures, p = 0.15) and clamp times when clips were used (8.4 +/- 1.5 min. vs. 10.1 +/- 1.3 min., p = 0.15). At re-operation all vessels were found patent without significant histological differences regarding the intimal reaction. VCS clips are a reliable alternative to sutures for vein patch angioplasty.

Physical exam and occult post-traumatic vascular lesions: implications for the evaluation and management of arterial injuries in modern warfare in the endovascular era.

Based on complexity of extremity wounds sustained in recent combat, arteriography had been used routinely in evaluations for delayed or occult arterial injuries. This report aims to quantitatively analyze the sensitivity and specificity of physical exam (PE) in predicting the presence of these injuries. United States service members sustaining extremity trauma in the Global War on Terrorism were evacuated to our medical center and evaluated by a senior vascular surgeon. Those with an abnormal PE, at risk based on wounding patterns, or previously treated for vascular injury underwent arteriography. Data from each patient were prospectively entered into a Vascular Injury registry. Comprehensive information about the injuries, interventions, arteriogram results, and any periprocedural complications were analyzed. Twenty-five endovascular or open surgical interventions were performed in forty-six of 99 patients that had lesions on arteriography. Seventy-three patients had a normal PE, of which 36 had lesions that prompted 6 subsequent interventions. Twenty-two of 26 patients with an abnormal PE had lesions that prompted 19 interventions. For PE, sensitivity was 38%, specificity was 90%, and positive predictive value (PPV) and negative predictive value (NPV) were 85% and 51%, respectively. In proximity injuries, PPV improved to 100%, but was only 15% sensitive with a NPV of 60%. In conclusion normal PE did not reliably predict post-traumatic arterial lesions in these military extremity injuries. These lesions are amenable to endovascular therapies, and should be considered in cases of complex trauma involving high amounts of energy, penetrating mechanisms, or wounding patterns in proximity to named vessels.

Sex differences in the effect of prepubertal GALP infusion on growth, metabolism and LH secretion.

The hypothalamic neuropeptide, galanin-like peptide (GALP), is known to have an effect on energy expenditure and reproduction in adult male rats, but little work has been done on prepubertal rats. We hypothesized that hypothalamic GALP is involved in physiological changes associated with the onset of puberty. To test this hypothesis, we first determined the postnatal ontogeny of GALP gene expression via in situ hybridization of developing male and female rat pups through adulthood. GALP gene expression was not observed in either male or female rat pups until after postnatal day (PND) 10 and did not reach adult-like levels until after weaning (PND25). To determine if exogenous GALP could induce the onset of puberty, PND25 male and female rats were implanted with lateral ventricular cannulas connected to an osmotic minipump that delivered either GALP or vehicle. GALP infusion significantly (p<0.05) increased body weight, food intake, and metabolic rate in male but not female rats compared to control infusion. After 2 weeks, GALP infusion had no significant effect on the onset of puberty, percent body fat, nor plasma levels of insulin, FSH or gonadal steroids in either sex; however, GALP did significantly (p<0.05) increase plasma levels of LH and leptin in male but not female rats and increased plasma growth hormone (GH) in both sexes. Our observations further demonstrate a sex difference in GALP responsiveness in prepubertal rats. These data suggest that GALP may be involved with the prepubertal increase in circulating leptin, LH, and GH resulting in an increase in metabolic rate and lean growth associated with puberty.

Evaluation of actigraphy and automated telephoned questionnaires to assess hypnotic effects in insomnia.

This study aimed to explore new methodologies in insomnia research, namely whether actigraphy was suitable to show hypnotic effects over weeks in insomnia, and to compare an automated method of questionnaire data collection with traditional methods. Thirty-eight insomniacs took part in a 5-week, double-blind, placebo-controlled study of the effects of 2 weeks of administration of temazepam 20 mg on sleep. Outcome measures were actigraphy and daily St Mary's Hospital Sleep Questionnaires (SMHSQ). Actigraphy was performed using Actiwatch (CNT) and analysed using both the automated Actiwatch sleep analysis software and non-parametric analysis of rest-activity rhythms. The questionnaires were administered as straightforward pencil-and-paper for half of the time and an automated telephoned system for the other half. The experimental paradigm allowed within-subject comparison of traditional and automated data collection, both on and off drug. Actigraphy showed a high degree of inter-subject variability but, nevertheless, some sleep variables (Fragmentation Index, Actual Sleep Time %) showed significant improvement during drug treatment, and Sleep Efficiency and Actual Sleep Time were significantly worsened during the first post-drug week. Nonparametric circadian rhythm analysis showed no significant effect. Subjective data from the SMHSQ showed significant drug effects and there was no significant difference in scores between the automated and pencil-and-paper methods; automated data collection was slightly more acceptable to patients and minimized data entry and management. Effect sizes using within-subject and between-subject comparisons were calculated for the subjective and objective measures to inform future studies

Upper-extremity deep venous thrombosis complicating whole-blood donation.

BACKGROUND: Up to 36 percent of blood donors may experience a donation-related complication. Fatigue, bruises, hematomas, and vasovagal reactions comprise the great majority of donor reactions and injuries. Serious complications are rare. CASE REPORT: A 20-year-old female taking the third-generation oral contraceptive desogestrel/ethinyl estradiol and ethinyl estradiol (Mircette) developed bruising and increased pain and swelling of her right arm over a 5-day period after whole-blood donation. She was a first-time donor and the venipuncture was reported as being mildly traumatic. There was no personal or family history of thrombosis. RESULTS: Ultrasound examination of her upper extremity revealed the presence of a deep venous thrombosis that required treatment with enoxaparin sodium for 5 days and warfarin for 6 months. Evaluation for thrombophilia was negative. The only risk factor for thrombosis was use of oral contraceptives. CONCLUSION: Although serious complications from whole-blood donation are rare, they may occur. Deep venous thrombosis should be considered in a donor presenting with increasing pain and swelling after blood donation.

Varicose veins possess greater quantities of MMP-1 than normal veins and demonstrate regional variation in MMP-1 and MMP-13.

BACKGROUND: Studies have reported that structural proteins such as elastin and collagen are decreased in varicose veins compared to normal controls. We hypothesized that the changes observed in varicose vein wall composition may be related to alterations in extracellular matrix remodeling proteins, such as the matrix metalloproteases and serine proteases. In addition we hypothesized that there may be regional variation in the expression of these enzymes within the leg. PATIENTS AND MATERIALS: One-centimeter segments of the proximal and distal greater saphenous vein (GSV) were obtained from patients undergoing ligation and stripping for venous insufficiency (vv) (n = 15) or GSV harvest in conjunction with coronary artery bypass grafting (CABG) (n = 7). All vv patients had incompetence of the GSV by color flow duplex. Vein specimens were examined for MMP-1, 3, and 13, tryptase, and GAPDH mRNA using semiquantitative RT-PCR analysis. Quantification of MMP-1 and 13 (active/latent forms) and tryptase was performed using Western blot analysis. Western blots were analyzed using scanning densitometry and standardized to normal controls and values expressed as the median densitometric index (D.I.). Nonparametric statistical methods (Wilcoxan signed rank test and Mann-Whitney U test) were used for analysis. RESULTS: We were able to amplify MMP-1, MMP-13, and tryptase mRNA from both proximal and distal segments of all greater saphenous veins studied. MMP-3 mRNA, however, was not found in either segment of any of the veins examined. A semiquantitative analysis of RT-PCR products comparing the ratio of MMP-1, MMP-13, or tryptase mRNA to GAPDH mRNA showed no difference between cases and controls nor proximal vs distal vein segments. Western blot analysis revealed larger quantities of MMP-1 in varicose veins than in nondiseased veins from CABG patients (48.0 +/- 36.7 D.I. vs 12.5 +/- 6.8 D.I., P = 0.036). Investigation into the regional variation of proteases revealed lower amounts of MMP-1 in distal than in proximal vein segments (37.9 +/- 35.0 D.I. vs 44.1 +/- 41.6 D.I., P = 0.01). Similarly, we found significantly less MMP-13 in distal segments of varicose veins than in proximal segments (152.8 +/- 130.0 D.I. vs 206.7 +/- 173.3 D.I., P = 0.006). CONCLUSIONS: This study found that MMP-1 protein is increased in varicose veins when compared to controls despite no differences in mRNA expression. In addition we found that there is regional variation of MMP-1 and MMP-13 in diseased varicose veins. Lower leg veins have significantly reduced amounts of these proteolytic enzymes when compared to veins of the upper thigh. These data suggest that posttranscriptional regulatory controls could be responsible for the observed differences.

Expression of the gene for the alpha-subunit of inhibin in human adrenocortical tumours.

BACKGROUND: To determine whether the pathogenesis of human adrenocortical tumours is associated with variations of inhibin expression, we assayed the mRNA of the alpha-subunit of inhibin in 5 normal adrenals and 48 adrenocortical tumours, including 10 paediatric tumours. RESULTS: mRNA of alpha-subunit of inhibin was detected in all adrenocortical tissues. It was similarly abundant in the three pathological groups of adult tumours (benign, suspect and malignant) and in normal adrenal tissues, irrespective of the hormonal pattern. However, in paediatric tumours, the levels of the mRNA for the alpha-subunit of inhibin were significantly higher than those in adult tumours (p < 0.01). CONCLUSION: Inhibin is more abundant in the foetal than in the adult adrenal cortex and therefore these data suggest that the paediatric tumours may have a foetal pattern.

Effects of fibronectin bonding on healing of high porosity expanded polytetrafluoroethylene grafts in pigs.

BACKGROUND: We developed a new fibronectin bonding to expanded polytetrafluoroethylene (ePTFE) and previously reported that, in a dog carotid implant model, fibronectin bonding improves graft healing in high porosity ePTFE grafts. The purpose of this study was to further investigate the effect of the fibronectin bonding on graft healing in a pig carotid implant model. METHODS: Fifteen pigs received a high porosity ePTFE graft treated with the fibronectin bonding (fibronectin-bonded graft) on one side and an untreated graft (non-bonded graft) on the contralateral side. The grafts were explanted at intervals of 3 and 6 weeks and subjected to histological studies. RESULTS: At 3 weeks, the neointima of fibronectin-bonded grafts was better organized than that of non-bonded grafts. At 6 weeks, the morphologic features of the neointima were the same in fibronectin-bonded and non-bonded grafts. The neointima was completely organized. CONCLUSIONS: Together with the previous results with the dog model, fibronectin bonding could be expected to improve healing of the high porosity ePTFE grafts in humans.

Facts and fiction surrounding the discovery of the venous valves.

Venous valves are delicate structures, the integrity of which is crucial for the normal function of the venous system. Their abnormalities lead to widespread disorders, ranging from chronic venous insufficiency to life-threatening thromboembolic phenomena. The discovery of the venous valves, however, has been the subject of hot controversy. Even though Fabricius ab Aquapendente is credited with the discovery by most historians, we demonstrate in this paper that other anatomists described them many years before Fabricius ab Aquapendente publicly demonstrated them in Padua in 1579. A thorough review of the historical literature surrounding the discovery of the venous valves was carried out from 1545 to the present under the supervision of the Medical History Department of our institution. Research was performed at the History of Medicine Division of the National Library of Medicine and through MEDLINE access to the medical literature. The Parisian Charles Estienne first mentioned the venous valves in his 1545 publication when he described "apophyses membranarum" in the veins of the liver. Lusitanus and Canano publicly demonstrated them in the azygos vein during cadaver dissections performed in Ferrera, Italy. The Parisian Jacques Sylvius described valves in the veins of the extremities in 1555. The work of these anatomists, however, could not achieve full recognition, because Andreas Vesalius, the leading anatomist at that time, was unable to confirm their findings and strongly denied the existence of venous valves. Vesalius's influence was so powerful that research on the subject was idle until 1579, when Fabricius ab Aquapendente "discovered" the venous valves. About the same time, the German Salomon Alberti published the first drawings of a venous valve (in 1585). William Harvey, a disciple of Fabricius ab Aquapendente, finally postulated the function of the venous valves, providing anatomical support for one of the greatest discoveries in medicine: the blood circulation. Therefore, our investigations revealed that Estienne and Canano discovered the venous valves in the 1530s. Fabricius ab Aquapendente's achievement was their full recognition 64 years later. However, it was not until 1628 that their function was fully understood, with the discovery of the blood circulation by William Harvey.

An historical tour of vascular injury management: from its inception to the new millennium.

Advances have been made in times of war. Lessons learned from these experiences should be studied in order to avoid the costly mistakes made previously. Fortunately, major conflicts have not been common recently. Therefore, military surgeons depend on the stable environment of civilian trauma and research to lead the way. Documentation and careful record keeping such as the Vietnam Vascular Registry are vital in assisting surgeons with lessons to be learned.

Repair of bilateral iliac artery aneurysms associated with a congenital pelvic kidney.

The association of iliac artery aneurysms with a congenital pelvic kidney is extremely rare. Although multiple techniques are well described for renal preservation with renal ectopia in the setting of aortic reconstruction, few reports exist describing techniques for renal preservation in the setting of bilateral iliac artery aneurysms. A case is presented of a middle-aged man with a 6-cm right common iliac artery aneurysm and a 3-cm left common iliac artery aneurysm and a right pelvic kidney. A double-proximal-clamp technique and temporary shunting to the pelvic kidney were used during the aneurysm repair. The technical aspects of this procedure are presented as well as a brief discussion of the various options for renal preservation with renal ectopia when repairing complex aneurysmal disease.