SMaRT lncRNA controls translation of a G-quadruplex-containing mRNA antagonizing the DHX36 helicase.

Guanine-quadruplexes (G4) included in RNA molecules exert several functions in controlling gene expression at post-transcriptional level; however, the molecular mechanisms of G4-mediated regulation are still poorly understood. Here, we describe a regulatory circuitry operating in the early phases of murine muscle differentiation in which a long non-coding RNA (SMaRT) base pairs with a G4-containing mRNA (Mlx-γ) and represses its translation by counteracting the activity of the DHX36 RNA helicase. The time-restricted, specific effect of lnc-SMaRT on the translation of Mlx-γ isoform modulates the general subcellular localization of total MLX proteins, impacting on their transcriptional output and promoting proper myogenesis and mature myotube formation. Therefore, the circuitry made of lnc-SMaRT, Mlx-γ, and DHX36 not only plays an important role in the control of myogenesis but also unravels a molecular mechanism where G4 structures and G4 unwinding activities are regulated in living cells.

Pulmonary hypertension due to a stiff left atrium: Speckle tracking equivalents of large V-waves.

Heart failure with preserved ejection fraction (HFpEF) is a widely heterogeneous clinical condition. Left ventricular diastolic dysfunction is the leading etiology of HFpEF, but there might be patients presenting with a predominant disease of the left atrium (LA). We report a case of HFpEF secondary to a stiff LA, in which we corroborated invasive hemodynamic assessment with LA strain analysis. Pathognomonic, tall V-waves were observed in the wedge position in the absence of mitral regurgitation and with a near-normal QRS-gated, pre-V-wave pressure, indicating that left ventricular diastolic dysfunction was not a major issue in this case. These hemodynamic findings were mirrored by very low LA strain values, compatible with a stiff and noncompliant chamber.

M6A reduction relieves FUS-associated ALS granules.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease due to gradual motoneurons (MN) degeneration. Among the processes associated to ALS pathogenesis, there is the formation of cytoplasmic inclusions produced by aggregation of mutant proteins, among which the RNA binding protein FUS. Here we show that, in neuronal cells and in iPSC-derived MN expressing mutant FUS, such inclusions are significantly reduced in number and dissolve faster when the RNA m6A content is diminished. Interestingly, stress granules formed in ALS conditions showed a distinctive transcriptome with respect to control cells, which reverted to similar to control after m6A downregulation. Notably, cells expressing mutant FUS were characterized by higher m6A levels suggesting a possible link between m6A homeostasis and pathological aggregates. Finally, we show that FUS inclusions are reduced also in patient-derived fibroblasts treated with STM-2457, an inhibitor of METTL3 activity, paving the way for its possible use for counteracting aggregate formation in ALS.

The Association Between Multidimensional Frailty and Poor Venous Accesses in a Geriatric Population: A Retrospective Study.

Since the association between frailty and difficulty in finding venous access (VA) is largely unexplored and unclear in geriatrics, the aim of this study is to demonstrate how multidimensional frailty is associated with bad VA in a population of older hospitalized people. Multidimensional Prognostic Index (MPI), based on eight different domains usually assessed in comprehensive geriatric assessment, was used for identifying multidimensional frailty; VA heritage was investigated using a questionnaire prepared by a trained nurse, based on clinical experience. Overall, 145 patients were included (mean age 78.6 ± 7.6; males 51.0%). Frailer people, identified as an MPI >0.66 (MPI 3), had a significantly higher presence of bad VA (49.0% vs. 27.3% in MPI 3 and MPI 1 groups, p = 0.045), no success at first attempt (49.0% vs. 22.7% in MPI 3 and MPI 1 groups, p = 0.03), reported more frequently pain during VA attempts (63.3% in MPI 3 vs. 27.3 in MPI 1, p = 0.002), and significantly higher scores in the Numeric Rating Scale compared to their robust counterparts. Taking robust participants in MPI 1 as reference, after adjusting for potential confounders, frailer people (MPI 3) were at increased odds of bad VA (odds ratio [OR] = 2.72; 95% confidence interval [CI]: 1.16-6.41; p = 0.02), not success at first attempt (OR = 3.67; 95% CI: 1.09-12.57; p = 0.04), and presence of pain during VA attempt (OR = 4.26; 95% CI: 1.30-13.92; p = 0.02). In conclusion, our study demonstrated an association between multidimensional frailty and bad VA in a population of older hospitalized people.

Real-world candidacy to mavacamten in a contemporary hypertrophic obstructive cardiomyopathy population.

AIMS: In the EXPLORER-HCM trial, mavacamten reduced left ventricular outflow tract obstruction (LVOTO) and improved functional capacity of symptomatic hypertrophic obstructive cardiomyopathy (HOCM) patients. We sought to define the potential use of mavacamten by comparing real-world HOCM patients with those enrolled in EXPLORER-HCM and assessing their eligibility to treatment. METHODS AND RESULTS: We collected information on HOCM patients followed up at 25 Italian HCM outpatient clinics and with significant LVOTO (i.e. gradient ≥30 mmHg at rest or ≥50 mmHg after Valsalva manoeuvre or exercise) despite pharmacological or non-pharmacological therapy. Pharmacological or non-pharmacological therapy resolved LVOTO in 1044 (61.2%) of the 1706 HOCM patients under active follow-up, whereas 662 patients (38.8%) had persistent LVOTO. Compared to the EXPLORER-HCM trial population, these real-world HOCM patients were older (62.1 ± 14.3 vs. 58.5 ± 12.2 years, p = 0.02), had a lower body mass index (26.8 ± 5.3 vs. 29.7 ± 4.9 kg/m2 , p < 0.0001) and a more frequent history of atrial fibrillation (21.5% vs. 9.8%, p = 0.027). At echocardiography, they had lower left ventricular ejection fraction (LVEF, 66 ± 7% vs. 74 ± 6%, p < 0.0001), higher left ventricular outflow tract gradients at rest (60 ± 27 vs. 52 ± 29 mmHg, p = 0.003), and larger left atrial volume index (49 ± 16 vs. 40 ± 12 ml/m2 , p < 0.0001). Overall, 324 (48.9%) would have been eligible for enrolment in the EXPLORER-HCM trial and 339 (51.2%) for treatment with mavacamten according to European guidelines. CONCLUSIONS: Real-world HOCM patients differ from the EXPLORER-HCM population for their older age, lower LVEF and larger atrial volume, potentially reflecting a more advanced stage of the disease. About half of real-world HOCM patients were found eligible to mavacamten.

The role of MDCT arthrography in the follow-up of scapholunate stabilisation.

PURPOSE: The aim of this study was to assess outcomes in a group of patients with scapholunate dissociation treated with stabilisation surgery (Brunelli-Stanley) and to compare arthrography with multidetector computed tomography (MDCT) with conventional radiography, the gold standard in the follow-up of wrist surgery. MATERIALS AND METHODS: Twelve patients (13 wrists) underwent surgery for scapholunate dissociation and were followed up with clinical (visual analogue scale, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Disabilities of the Arm, Shoulder, and Hand) and radiological assessment (conventional radiography and CT arthrography). Conventional radiography was assessed for: the scapholunate gap, scapholunate angle, radiolunate angle, capitate-lunate angle, and carpal height index; the CT arthrography images were also evaluated for: the distance between the dorsal exit hole of the bone tunnel and the proximal scaphoid pole, the thickness and tension of the flexor carpi radialis (FCR) strip, and any signs of joint degeneration. RESULTS: Analysis of the data from conventional radiography and MDCT arthrography demonstrated a significant statistical correlation among the measurements obtained on the radiograms and multiplanar CT reconstructions and the patients' clinical outcome. CONCLUSIONS: Our results show that MDCT arthrography has the same value as conventional radiography in the evaluation of standard parameters (scapholunate gap, scapholunate angle, radiolunate angle, capitolunate angle, carpal height index), but in addition provides an accurate delineation of the FCR tendon graft, allowing differentiation of its thickness, direction and degree of tension.

The m6A reader YTHDC1 and the RNA helicase DDX5 control the production of rhabdomyosarcoma-enriched circRNAs.

N6-Methyladenosine (m6A) is well-known for controlling different processes of linear RNA metabolism. Conversely, its role in the biogenesis and function of circular RNAs (circRNAs) is still poorly understood. Here, we characterize circRNA expression in the pathological context of rhabdomyosarcoma (RMS), observing a global increase when compared to wild-type myoblasts. For a set of circRNAs, such an increase is due to the raised expression of the m6A machinery, which we also find to control the proliferation activity of RMS cells. Furthermore, we identify the RNA helicase DDX5 as a mediator of the back-splicing reaction and as a co-factor of the m6A regulatory network. DDX5 and the m6A reader YTHDC1 are shown to interact and to promote the production of a common subset of circRNAs in RMS. In line with the observation that YTHDC1/DDX5 depletion reduces RMS proliferation, our results provide proteins and RNA candidates for the study of rhabdomyosarcoma tumorigenicity.

Single-photon microscopy to study biomolecular condensates.

Biomolecular condensates serve as membrane-less compartments within cells, concentrating proteins and nucleic acids to facilitate precise spatial and temporal orchestration of various biological processes. The diversity of these processes and the substantial variability in condensate characteristics present a formidable challenge for quantifying their molecular dynamics, surpassing the capabilities of conventional microscopy. Here, we show that our single-photon microscope provides a comprehensive live-cell spectroscopy and imaging framework for investigating biomolecular condensation. Leveraging a single-photon detector array, single-photon microscopy enhances the potential of quantitative confocal microscopy by providing access to fluorescence signals at the single-photon level. Our platform incorporates photon spatiotemporal tagging, which allowed us to perform time-lapse super-resolved imaging for molecular sub-diffraction environment organization with simultaneous monitoring of molecular mobility, interactions, and nano-environment properties through fluorescence lifetime fluctuation spectroscopy. This integrated correlative study reveals the dynamics and interactions of RNA-binding proteins involved in forming stress granules, a specific type of biomolecular condensates, across a wide range of spatial and temporal scales. Our versatile framework opens up avenues for exploring a broad spectrum of biomolecular processes beyond the formation of membrane-less organelles.

The long noncoding RNA Charme supervises cardiomyocyte maturation by controlling cell differentiation programs in the developing heart.

Long noncoding RNAs (lncRNAs) are emerging as critical regulators of heart physiology and disease, although the studies unveiling their modes of action are still limited to few examples. We recently identified pCharme, a chromatin-associated lncRNA whose functional knockout in mice results in defective myogenesis and morphological remodeling of the cardiac muscle. Here, we combined Cap-Analysis of Gene Expression (CAGE), single-cell (sc)RNA sequencing, and whole-mount in situ hybridization analyses to study pCharme cardiac expression. Since the early steps of cardiomyogenesis, we found the lncRNA being specifically restricted to cardiomyocytes, where it assists the formation of specific nuclear condensates containing MATR3, as well as important RNAs for cardiac development. In line with the functional significance of these activities, pCharme ablation in mice results in a delayed maturation of cardiomyocytes, which ultimately leads to morphological alterations of the ventricular myocardium. Since congenital anomalies in myocardium are clinically relevant in humans and predispose patients to major complications, the identification of novel genes controlling cardiac morphology becomes crucial. Our study offers unique insights into a novel lncRNA-mediated regulatory mechanism promoting cardiomyocyte maturation and bears relevance to Charme locus for future theranostic applications.

A KO mouse model for the lncRNA Lhx1os produces motor neuron alterations and locomotor impairment.

Here, we describe a conserved motor neuron-specific long non-coding RNA, Lhx1os, whose knockout in mice produces motor impairment and postnatal reduction of mature motor neurons (MNs). The ER stress-response pathway result specifically altered with the downregulation of factors involved in the unfolded protein response (UPR). Lhx1os was found to bind the ER-associated PDIA3 disulfide isomerase and to affect the expression of the same set of genes controlled by this protein, indicating that the two factors act in conjunction to modulate the UPR. Altogether, the observed phenotype and function of Lhx1os indicate its important role in the control of MN homeostasis and function.

Lnc-SMaRT Translational Regulation of Spire1, A New Player in Muscle Differentiation.

The destiny of a messenger RNA is determined from a combination of in cis elements, like peculiar secondary structures, and in trans modulators, such as RNA binding proteins and non-coding, regulatory RNAs. RNA guanine quadruplexes belong to the first group: these strong secondary structures have been characterized in many mRNAs, and their stabilization or unwinding provides an additional step for the fine tuning of mRNA stability and translation. On the other hand, many cytoplasmic long non-coding RNAs intervene in post-transcriptional regulation, frequently by direct base-pairing with their mRNA targets. We have previously identified the lncRNA SMaRT as a key modulator of the correct timing of murine skeletal muscle differentiation; when expressed, lnc-SMaRT interacts with a G-quadruplex-containing region of Mlx-γ mRNA, therefore inhibiting its translation by counteracting the DHX36 helicase activity. The "smart" mode of action of lnc-SMaRT led us to speculate whether this molecular mechanism could be extended to other targets and conserved in other species. Here, we show that the molecular complex composed by lnc-SMaRT and DHX36 also includes other mRNAs. We prove that lnc-SMaRT is able to repress Spire1 translation through base-pairing with its G-quadruplex-forming sequence, and that Spire1 modulation participates to the regulation of proper skeletal muscle differentiation. Moreover, we demonstrate that the interaction between DHX36 and lnc-SMaRT is indirect and mediated by the mRNAs present in the complex. Finally, we suggest an extendibility of the molecular mechanism of lnc-SMaRT from the mouse model to humans, identifying potential functional analogues.

Current patterns of beta-blocker prescription in cardiac amyloidosis: an Italian nationwide survey.

AIMS: The use of beta-blocker therapy in cardiac amyloidosis (CA) is debated. We aimed at describing patterns of beta-blocker prescription through a nationwide survey. METHODS AND RESULTS: From 11 referral centres, we retrospectively collected data of CA patients with a first evaluation after 2016 (n = 642). Clinical characteristics at first and last evaluation were collected, with a focus on medical therapy. For patients in whom beta-blocker therapy was started, stopped, or continued between first and last evaluation, the main reason for beta-blocker management was requested. Median age of study population was 77 years; 81% were men. Arterial hypertension was found in 58% of patients, atrial fibrillation (AF) in 57%, and coronary artery disease in 16%. Left ventricular ejection fraction was preserved in 62% of cases, and 74% of patients had advanced diastolic dysfunction. Out of the 250 CA patients on beta-blockers at last evaluation, 215 (33%) were already taking this therapy at first evaluation, while 35 (5%) were started it, in both cases primarily because of high-rate AF. One-hundred-nineteen patients (19%) who were on beta-blocker at first evaluation had this therapy withdrawn, mainly because of intolerance in the presence of heart failure with advanced diastolic dysfunction. The remaining 273 patients (43%) had never received beta-blocker therapy. Beta-blockers usage was similar between CA aetiologies. Patients taking vs. not taking beta-blockers differed only for a greater prevalence of arterial hypertension, coronary artery disease, AF, and non-restrictive filling pattern (P < 0.01 for all) in the former group. CONCLUSIONS: Beta-blockers prescription is not infrequent in CA. Such therapy may be tolerated in the presence of co-morbidities for which beta-blockers are routinely used and in the absence of advanced diastolic dysfunction.

Nocturnal Arrhythmias and Heart-Rate Swings in Patients With Obstructive Sleep Apnea Syndrome Treated With Beta Blockers.

Background The higher cardiovascular variability and the increased prevalence of arrhythmias in patients with obstructive sleep apneas may contribute to their higher rate of fatal events during sleep. In this regard, the use of beta blockers (BB) is debated because they may induce bradyarrhythmias and alter the pattern of heart rate changes induced by apneas. Thus, the aim of our study is to quantify peri-apneic heart-rate swings and prevalence of nocturnal bradyarrhythmias in BB-treated and BB-naïve patients with obstructive sleep apnea. Methods and Results Our real-life, retrospective, cohort study analyzed data from patients with obstructive sleep apnea after a basal cardiorespiratory polysomnography. Among 228 eligible participants, we enrolled 78 BB-treated and 88 BB-naïve patients excluding those treated with antiarrhythmic drugs or pacemakers, or with uninterpretable ECG traces during polysomnography. In each patient, type and frequency of arrhythmias were identified and peri-apneic changes of RR intervals were evaluated for each apnea. BB-treated patients were older and with more comorbidities than BB-naïve patients, but had similar obstructive sleep apnea severity, similar frequency of arrhythmic episodes, and similar prevalence of bradyarrhythmias. Apnea-induced heart-rate swings, unadjusted for age, showed lower RR interval changes in BB-treated (133.5±63.8 ms) than BB-naïve patients (171.3±87.7 ms, P=0.01), lower RR interval increases during apneas (58.5±28.5 versus 74.6±40.2 ms, P=0.01), and lower RR interval decreases after apneas (75.0±42.4 versus 96.7±55.5 ms, P<0.05). Conclusions BB appear to be safe in patients with obstructive sleep apnea because they are not associated with worse episodes of nocturnal bradyarrhythmias and even seem protective in terms of apnea-induced changes of heart rate.

Trans-generational epigenetic regulation associated with the amelioration of Duchenne Muscular Dystrophy.

Exon skipping is an effective strategy for the treatment of many Duchenne Muscular Dystrophy (DMD) mutations. Natural exon skipping observed in several DMD cases can help in identifying novel therapeutic tools. Here, we show a DMD study case where the lack of a splicing factor (Celf2a), which results in exon skipping and dystrophin rescue, is due to a maternally inherited trans-generational epigenetic silencing. We found that the study case and his mother express a repressive long non-coding RNA, DUXAP8, whose presence correlates with silencing of the Celf2a coding region. We also demonstrate that DUXAP8 expression is lost upon cell reprogramming and that, upon induction of iPSCs into myoblasts, Celf2a expression is recovered leading to the loss of exon skipping and loss of dystrophin synthesis. Finally, CRISPR/Cas9 inactivation of the splicing factor Celf2a was proven to ameliorate the pathological state in other DMD backgrounds establishing Celf2a ablation or inactivation as a novel therapeutic approach for the treatment of Duchenne Muscular Dystrophy.

Ultrasound-guided removal of foreign bodies: personal experience.

Foreign bodies (FBs) retained in the soft tissues are a common reason for medical consultation, and usually consist of wooden or metal splinters or glass shards. Failure to remove foreign bodies is likely to give rise to acute or late complications, such as allergies, inflammation or infection, that may be severe. The surgical removal of an FB is invasive, costly and technically challenging. The procedure may fail in some cases and carries the risk of complications. Our study describes a technique for the ultrasound-guided removal of an FB, devised from our experience, and demonstrates its advantages over the standard surgical procedure. Sixty-two patients (43 males and 19 females aged from 9 to 65 years, median age 31 years) presented at our institution between October 2005 and June 2008 with suspected foreign bodies retained in the soft tissues of various body districts. Radiographic and/or ultrasound diagnosis was established by a radiologist expert in musculoskeletal sonography. The same radiologist helped by a nurse subsequently undertook the ultrasound-guided removal in the outpatient's clinic according to the technique described in the paper. ATL 5000 and PHILIPS iu22 ultrasound systems were used with high-frequency linear-array probes, sterile material, local anaesthetic (lidocaine 2%), scapels and surgical forceps. Antibiotic prophylaxis with amoxicillin and clavulanic acid were prescribed to all patients for 7 days after the procedure. Ninety-five FBs (39 glass, 35 metal, 17 vegetable, 2 plastic, 2 stone) were successfully removed under ultrasound guidance in all patients and the procedure took between 15 and 30 min. No complications arose either during or after the procedure. Seventy-five skin incisions were made and the wounds closed with Steri-Strips in 73/75 cases, whereas skin sutures were used in 2/75 cases. No complications arose either during or after the procedure. Ultrasound-guided removal of an FB retained in the soft tissues is a good alternative to surgery as is its relatively straightforward, inexpensive, repeatable and carries a low risk of complications. In addition, failure to remove an FB does not preclude traditional surgical removal. The advantages of this real-time procedure and the use of small instruments minimize bleeding time and avoid injury to surrounding structures. Patient compliance is enhanced by the fact that the procedure has little or no aesthetic impact. These encouraging results suggest ultrasound-guided removal as a first-choice procedure for the extraction of foreign bodies.

Non-coding RNAs Shaping Muscle.

In 1957, Francis Crick speculated that RNA, beyond its protein-coding capacity, could have its own function. Decade after decade, this theory was dramatically boosted by the discovery of new classes of non-coding RNAs (ncRNAs), including long ncRNAs (lncRNAs) and circular RNAs (circRNAs), which play a fundamental role in the fine spatio-temporal control of multiple layers of gene expression. Recently, many of these molecules have been identified in a plethora of different tissues, and they have emerged to be more cell-type specific than protein-coding genes. These findings shed light on how ncRNAs are involved in the precise tuning of gene regulatory mechanisms governing tissues homeostasis. In this review, we discuss the recent findings on the mechanisms used by lncRNAs and circRNAs to sustain skeletal and cardiac muscle formation, paying particular attention to the technological developments that, over the last few years, have aided their genome-wide identification and study. Together with lncRNAs and circRNAs, the emerging contribution of Piwi-interacting RNAs and transfer RNA-derived fragments to myogenesis will be also discussed, with a glimpse on the impact of their dysregulation in muscle disorders, such as myopathies, muscle atrophy, and rhabdomyosarcoma degeneration.

Impact of obstructive sleep apnea on cardiac organ damage in patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Both obstructive sleep apnea (OSA) and cardiac organ damage have a crucial role in acute ischemic stroke. Our aim is to explore the relationship between OSA and cardiac organ damage in acute stroke patients. METHODS: A total of 130 consecutive patients with acute ischemic stroke were enrolled. Patients underwent full multichannel 24-h polysomnography for evaluation of OSA and echocardiography to evaluate left ventricle (LV) mass index (LV mass/BSA, LV mass/height), thickness of interventricular septum (IVS) and posterior wall (LVPW), LV ejection fraction and left atrium enlargement. Information on occurrence of arterial hypertension and its treatment before stroke was obtained from patients' history. RESULTS: 61.9% (70) of patients, mostly men (67.1%), with acute stroke had OSA (AHI > 10). Patients with acute stroke and OSA showed a significant increase (P < 0.05) of LV mass index, IVS and LVPW thickness and a significant left atrial enlargement as compared with patients without OSA. LV ejection fraction was not significantly different in stroke patients with and without OSA and was within normal limits. No relationship was found among cardiac alterations, occurrence of OSA and history of hypertension. CONCLUSION: Acute stroke patients with OSA had higher LV mass and showed greater left atrial enlargement than patients without OSA. This study confirms the high prevalence of OSA in stroke patients, suggesting also an association between OSA and cardiac target organ damage. Our finding of structural LV abnormalities in acute stroke patients with OSA suggests a potential role of OSA as contributing factor in determining both cerebrovascular and cardiac damage, even in absence of clear link with a history of blood pressure elevation.

The Long Non-coding RNA lnc-31 Interacts with Rock1 mRNA and Mediates Its YB-1-Dependent Translation.

Cytoplasmic long non-coding RNAs have been shown to act at many different levels to control post-transcriptional gene expression, although their role in translational control is poorly understood. Here, we show that lnc-31, a non-coding RNA required for myoblast proliferation, promotes ROCK1 protein synthesis by stabilizing its translational activator, YB-1. We find that lnc-31 binds to the Rock1 mRNA as well as to the YB-1 protein and that translational activation requires physical interaction between the two RNA species. These results suggest a localized effect of YB-1 stabilization on the Rock1 mRNA. ROCK1 upregulation by lnc-31, in proliferative conditions, correlates well with the differentiation-repressing activity of ROCK1. We also show that, upon induction of differentiation, the downregulation of lnc-31, in conjunction with miR-152 targeting of Rock1, establishes a regulatory loop that reinforces ROCK1 repression and promotes myogenesis.

Gross hematuria caused by a congenital intrarenal arteriovenous malformation: a case report.

INTRODUCTION: We report the case of a woman who presented with gross hematuria and was treated with a percutaneous embolization. CASE PRESENTATION: A 48-year-old Caucasian woman presented with gross hematuria, left flank pain, and clot retention. The patient had no history of renal trauma, hypertension, urolithiasis, or recent medical intervention with percutaneous instrumentation. The patient did not report any bleeding disorder and was not taking any medication. Her systolic and diastolic blood pressure values were normal at presentation. The patient had anemia (8 mg/dL) and tachycardia (110 bpm). She underwent color and spectral Doppler sonography, multi-slice computed tomography, and angiography of the kidneys, which showed a renal arteriovenous malformation pole on top of the left kidney. CONCLUSIONS: The feeding artery of the arteriovenous malformation was selectively embolized with a microcatheter introduced using a right transfemoral approach. By using this technique, we stopped the bleeding, preserved renal parenchymal function, and relieved the patient's symptoms. The hemodynamic effects associated with the abnormality were also corrected.