Methylenetetrahydrofolate reductase mutation and neural tube defects.
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Adult↗
Biomedical subjects
J L Mills
Publications and source records attributed to J L Mills.
Birth defects in offspring of adult survivors of childhood acute lymphoblastic leukemia. A Childrens Cancer Group/National Institutes of Health Report.
BACKGROUND: It is not known if therapy for acute lymphoblastic leukemia (ALL) during childhood increases the risk of birth defects in the offspring of adult survivors. The Childrens Cancer Group (CCG), in collaboration with the National Institutes of Health (NIH), conducted a retrospective cohort study of adults successfully treated for childhood ALL to determine if their offspring had an increased incidence of birth defects compared with the offspring of their sibling controls. METHODS: Study subjects were patients who had been enrolled on CCG ALL protocols, who were treated for ALL prior to age 20, who survived at least 2 years, and who were at least age 18. Survivors (N=593) and sibling controls (N=409) were interviewed by telephone. RESULTS: The mean age of survivors was 22.6 years; the mean age of controls was 25.2 years. Among survivors, 93 (15.7%) had given birth to or fathered a total of 140 live-born offspring, (mean age, 3.4 years), and 122 (29.8%) sibling controls had given birth to or fathered a total of 228 live-born offspring (mean age, 5.9 years). There was no difference in the rate of birth defects between offspring of survivors and offspring of controls (3.6% [5 of 140] vs. 3.5% [8 of 228]; relative risk, 1.02; 95% confidence interval, 0.34, 3.05). No specific ALL therapy was associated with an increased rate of birth defects. Only female survivors reported offspring with birth defects (P=0.0735). CONCLUSIONS: Adult survivors of childhood ALL in our study were not at greater risk for having offspring with birth defects compared with sibling controls. Although this is the largest group of ALL survivors studied to date, the number of offspring is still not large enough to detect small but significant differences in rare events such as birth defects. Studies following this cohort into later adulthood and studies of additional ALL survivors are necessary to adequately quantify the risks.
Adult↗
Prospective study showing that antisperm antibodies are not associated with pregnancy losses.
OBJECTIVE: To obtain prospective data on the relationship between presence of antisperm antibodies in maternal sera and first trimester pregnancy losses. DESIGN: First trimester sera obtained from diabetic and nondiabetic women recruited within 21 days of conception were analyzed using the indirect immunobead test for immunoglobulin (Ig)G, IgA, and IgM antisperm antibodies. Regional binding also was considered: sperm head, midpiece, and sperm tail. Results were correlated with pregnancy outcome. SETTING: Five university centers. PATIENTS: One hundred eleven women who experienced pregnancy loss (55 diabetic; 56 nondiabetic) were matched 2:1 with 104 diabetic and 116 nondiabetic women (controls) who subsequently had a normal liveborn infant. INTERVENTION: None. MAIN OUTCOME MEASURE: Pregnancy outcome (spontaneous abortion, liveborn) correlated with presence or absence of antisperm antibodies. RESULTS: Analyzing samples without knowledge of clinical status, no differences were observed with respect to IgG, IgA, and IgM binding when a positive test was defined as 50% of sperm showing antibody binding. Likewise, no association was found for IgG and IgM antisperm antibodies at 20% binding. The only positive finding was observed for IgA antisperm antibodies at 20% binding (Fisher's Exact test). This one positive finding merely could reflect multiple comparisons. No significant differences between groups were observed when analysis was stratified according to location of antibody binding (head, midpiece, tail tip, entire sperm). When the sample was stratified into those having and not having a prior loss, a relationship between antisperm antibodies and pregnancy loss still was not evident. CONCLUSION: Further work is necessary to determine whether IgA antisperm antibodies truly are associated with pregnancy loss or whether antisperm antibodies play any role in repetitive aborters. Findings in this study suggest that antisperm antibodies do not play a major role in pregnancy loss.
Abortion, Spontaneous↗
Comparative analysis of percutaneous transluminal angioplasty and operation for renal revascularization.
Contemporary patients requiring renal revascularization often have diffuse atherosclerosis, and increasingly undergo intervention for salvage of renal function rather than control of hypertension alone. Risk-benefit analyses and outcome data are difficult to obtain, since few reports have analyzed a modern, unselected series of consecutive patients subjected to renal revascularization by surgical as well as interventional techniques. We reviewed our 5-year experience with 76 consecutive renal revascularizations in 63 patients. Indications for intervention were hypertension and renal salvage, 60 percent (n = 38); hypertension, 24 percent (n = 15); renal salvage, 9.5 percent (n = 6); and other, 6.5 percent (n = 4). Ninety-four percent (n = 59) of patients had atherosclerotic occlusive disease of the renal arteries. Percutaneous transluminal angioplasty (PTA) was initially performed on 18 renal arteries in 16 patients, of whom 56 percent (n = 9) subsequently required surgical reconstruction. Fifty-eight surgical reconstructions were performed in 56 patients and consisted of aortorenal bypass (n = 27), aortorenal endarterectomy (n = 18), and extra-anatomic bypass (n = 13). Concomitant aortic replacement was required in 57 percent (n = 32) of patients. Preoperative risk factors and operative indications did not differ between the PTA and surgical reconstruction groups. Morbidity and mortality rates associated with PTA were 33 percent and 4.8 percent, respectively, while for surgical treatment the morbidity rate was 7 percent and the mortality rate 5.3 percent (P = NS). Functional improvement was achieved in 74 percent of surgically treated patients compared with 22 percent of PTA-treated patients (P < 0.01). Actuarial renal artery primary patency at 48 months was 81 percent for the surgery group and 17 percent for the PTA group (P < 0.01). Aortorenal bypass, endarterectomy, and extra-anatomic bypass were equally efficacious (P > 0.05). The results of surgical reconstruction are excellent, offering more durable patency and functional improvement than PTA, without increased risk. The operation should be tailored to fit the individual patient's disease, since the results of endarterectomy and bypass procedures are equivalent.
Aged↗
Secondary recurrent carotid stenosis.
PURPOSE: Recurrent carotid stenosis after carotid endarterectomy has been extensively reported. The occurrence, however, of another ipsilateral restenosis that requires a third carotid operation is rare. The purpose of this study was to evaluate possible risk factors and the most efficacious management of the patient with "secondary" recurrent carotid stenosis. METHODS: A survey of the Southern Association for Vascular Surgery was performed, and 31 patients who had had surgery for secondary recurrent carotid stenosis were identified. RESULTS: The mean interval between the recurrent stenosis operation and secondary recurrent carotid stenosis was 39.8 months (range, 9 to 83 months). At the third operation, 21 patients underwent carotid patch angioplasty and 10 underwent carotid resection with an interposition saphenous vein graft. No postoperative strokes or deaths occurred; three patients (10%) had a peripheral nerve injury. Nine early (< 24 mo) secondary recurrent carotid stenoses occurred, and these patients underwent patch angioplasty. Twenty-three female, cigarette-smoking patients and 20 patients with elevated lipid levels had early restenosis and were identified as being at high risk for the development of another stenosis. A fourth significant stenosis developed in five of these high-risk patients who had saphenous vein patch angioplasty at their third carotid operation; eight other high-risk patients had carotid resection with an interposition saphenous vein graft, and no other stenosis developed. CONCLUSION: Patients who have secondary recurrent carotid stenoses can safely undergo a third carotid operation. Female habitual smokers with elevated lipid levels and an early restenosis appear to be at high risk of secondary recurrent carotid stenoses. When surgery is necessary, carotid resection with an interposition saphenous vein graft appears more durable than patch angioplasty.
Adult↗
The relative contributions of carotid duplex scanning, magnetic resonance angiography, and cerebral arteriography to clinical decisionmaking: a prospective study in patients with carotid occlusive disease.
PURPOSE: Recent reports suggest that 80% to 90% of patients can safely undergo carotid endarterectomy on the basis of duplex scanning alone without cerebral angiography. Other investigators have recommended that a complementary imaging study such as magnetic resonance angiography (MRA) also be obtained. METHODS: We prospectively evaluated 103 consecutive patients with carotid occlusive disease. Eighty percent of patients were symptomatic. All 103 patients underwent duplex scanning and arteriography. Additional noninvasive tests included computed tomography, magnetic resonance imaging, and MRA in 50%, 56%, and 48% of patients, respectively. At a multispecialty conference all studies except angiograms were reviewed, and a treatment decision was made by a panel of attending vascular surgeons, neurosurgeons, and neurologists. The cerebral angiograms then were reviewed and changes made to final treatment plans were noted. RESULTS: After review of noninvasive studies, 30 of 103 of patients (29%) were believed to require arteriography because of diagnostic uncertainty of carotid occlusion in three patients, suggestion of nonatherosclerotic disease in four, suggestion of proximal disease in two, suboptimal noninvasive studies in one, and uncertainty of therapy despite good-quality noninvasive studies in 20 patients primarily with borderline stenoses and unclear symptoms. In 10 of these 30 patients (33%) management decisions were changed on the basis of angiogram results. Of the remaining 73 patients (71%) in whom the panel felt comfortable proceeding with operative or medical therapy without angiography, only one patient (1.4%) would have had management altered by results of angiography. MRA results concurred with duplex findings in 92% of studies, but did not alter management in any patient. CONCLUSIONS: In patients with good-quality duplex images, focal atherosclerotic bifurcation disease, and clear clinical presentation, treatment decisions can be made without arteriography. In 30% of patients angiography is useful in clarifying decisionmaking. MRA is unlikely to influence management decisions and is thus rarely indicated.
Aged↗
Infectious processes: an infrequent cause of first trimester spontaneous abortions.
A systematic assessment of infections beginning early in pregnancy is necessary to determine the true role of infections in pregnancy loss, given that infections could readily arise only after fetal demise. To this end, we have prospectively determined the frequency of infections in pregnant women who were subjects in a multi-centre US study. Insulin-dependent diabetic subjects and controlled subjects were recruited either before conception (86%) or at the latest within 21 days of conception (14%). We collected data prospectively on all important risk factors and potential confounding variables, seeing 386 diabetic subjects weekly and 432 control subjects every other week during the first trimester. At each visit we inquired about untoward events and explicitly about fever or infections. We found no clinical evidence that infection occurred more often in the 116 subjects experiencing pregnancy loss as compared to the 702 having successful pregnancies. This held both for the 2 week interval in which a given loss was recognized clinically as well as in the prior 2 week interval. Similar findings were not only observed for both the control as well as diabetic subjects but also when data were stratified by genital infection only or by systemic infection only. Our prospective data suggest that the attributable risk of infection in first trimester spontaneous abortion is small.
Abortion, Spontaneous↗
Homocysteine and neural tube defects.
It is now well established that folic acid, when taken periconceptionally, can prevent many neural tube defects. It is also becoming clear that folic acid does not work by correcting a nutritional deficiency in pregnant women. Rather, it appears that a metabolic defect is responsible for these neural tube defects and that this defect or defects can be corrected by a sufficiently large dose of folic acid. Our recent work demonstrates that homocysteine metabolism is likely to be the critical pathway affected by folic acid. We have demonstrated significantly higher homocysteine levels in women carrying affected fetuses than in control women. These findings indicate that one of the enzymes responsible for homocysteine metabolism is likely to be abnormal in affected pregnancies. Animal studies suggest that the conversion of homocysteine to methionine could be the critical step. Rat embryos in culture require methionine for neural tube closure. Methionine synthase, cystathionine synthase, and 5,10 methylene tetrahydrofolate reductase are all important in the metabolism of homocysteine in humans. If methionine synthase is the critical enzyme, it would raise the interesting public health issue that vitamin B-12 might be able to stimulate the abnormal enzyme as folic acid does. Adding vitamin B-12 might make it possible to reduce the dose of folic acid required in fortified food, thus allaying concerns about overexposure to folic acid.
5-Methyltetrahydrofolate-Homocysteine S-Methyltran↗
Neurofibromatosis and arterial aneurysms.
Neurofibromatosis (NF) is a common autosomal dominant disease characterized by the development of hamartomatous or neoplastic lesions due to the proliferation of neural crest cells. An association of aneurysmal arterial lesions with NF, which may have catastrophic complications, has been rarely reported. Our recent experiences with the diagnosis and management of three male NF patients with aneurysms is described. A 19-year-old-man with refractory hypertension due to unilateral, complex, unreconstructable renal artery aneurysms was successfully treated by nephrectomy. Histopathology demonstrated intramural renal artery Schwann cell proliferation. A 44-year-old patient underwent ligation of a ruptured superior mesenteric artery aneurysm. Finally, a femoral-popliteal artery saphenous vein bypass graft with aneurysm exclusion was performed in a 58-year-old-man with a 3.5 cm symptomatic popliteal artery aneurysm. In NF, the underlying pathology in large arteries is intramuscular Schwann cell proliferation with secondary fibrosis. Mesodermal dysplasia may affect small arteries resulting in stenosis, post-stenotic dilatation, or aneurysmal degeneration. Clinicians should be aware of the unusual association of NF with aneurysms, particularly the occult development of visceral and renal artery aneurysms. These lesions are subject to sudden rupture with potentially devastating consequences, and they mandate a high index of suspicion in NF patients.
Adult↗
Protecting the embryo from X-rated drugs.
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Abnormalities, Drug-Induced↗
Homocysteine metabolism in pregnancies complicated by neural-tube defects.
Folic acid taken around the time of conception can prevent many neural-tube defects. Women with low-normal vitamin B12 values may also be at increased risk. We considered whether homocysteine metabolism via the enzyme methionine synthase, which requires both folate and B12, could be the critical defect in folate-related neural tube defects. Blood was obtained during pregnancies that produced 81 infants with neural-tube defects and 323 normal children. Samples were assayed for homocysteine, methylmalonic acid, plasma folate, red-cell folate, and B12. Mothers of children with neural-tube defects had significantly higher homocysteine values (8.62 [SD 2.8] mumol/L) than did B12-matched controls (7.96 [2.5] mumol/L, p = 0.03). The difference was significant (p = 0.004) in the lower half of the B12 distribution after adjusting for plasma folate. Our study shows that an abnormality in homocysteine metabolism, apparently related to methionine synthase, is present in many women who give birth to children with neural-tube defects. Overcoming this abnormality is likely to be the mechanism by which folic acid prevents neural-tube defects. These findings suggest that the most effective periconceptional prophylaxis to prevent neural-tube defects may require B12 as well as folic acid.
5-Methyltetrahydrofolate-Homocysteine S-Methyltran↗
Antistaphylococcal activity of rifampin-bonded gelatin-impregnated Dacron grafts.
The affinity of rifampin to bond to Dacron permits implantation of a vascular prosthesis with anti-staphylococcal bioactivity. The performance of rifampin-bonded Dacron grafts was evaluated in vitro and in vivo to develop a bonding technique with optimal graft bioactivity which was then used for in situ reconstruction of a biofilm graft infection. In vitro bioactivity was measured at 24-hr intervals for three types of Dacron prostheses (plain, gelatin, and collagen-impregnated) exposed to rifampin at varied concentrations and immersion times. Gelatin-impregnated grafts demonstrated superior bioactivity (P < 0.05). Rifampin concentration and graft type had a greater effect on bioactivity than immersion time (P < 0.01). Gelatin-impregnated grafts immersed in a 60 mg/ml rifampin solution for 15 min produced optimum bioactivity. Six grafts prepared in this fashion were used to replace the canine aorta. The level and duration of in vivo antistaphylococcal activity to Staphylococcus aureus and Staphylococcus epidermidis were less (P < 0.05) than those measured in vitro, but rifampin levels exceeded the study strain maximum inhibitory concentration for up to 48 hr. In a canine model, the rifampin-bonded gelatin-impregnated (N = 14) or nonbonded control (N = 10) grafts were used as in situ replacement for an established aortic graft infection caused by S. epidermidis. Replacement with a rifampin-bonded graft resulted in successful anatomic healing of perigraft and anastomotic tissue. Persistent biofilm colonization was confirmed in 8 of 10 controls versus 4 of 14 rifampin-bonded grafts (P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Periconceptional vitamin supplementation to prevent neural tube defects: how can we do it?
The discovery that folic acid can reduce neural tube defect rates offers a great opportunity for primary prevention. Unfortunately, women must receive the folic acid before or immediately after conception, before many know that they are pregnant. Thus, we are faced with a difficult choice: (1) ask all women at risk of getting pregnant to take supplements, or (2) fortify the food supply to ensure that all women at risk receive additional folic acid. Neither approach is ideal. Many women will not take vitamin supplements. Fortification at sufficiently high levels to provide all women with 400 micrograms of folic acid will expose other segments of the population to unacceptably high levels. Because many women of child-bearing age are unaware of the benefits of folic acid, a vigorous education campaign should begin immediately to encourage women at risk to take supplements. Adding 70 micrograms of folic acid per 100 g of grain could be justified easily because this amount is removed from grain in processing. If it is technically feasible, adding up to 140 micrograms is likely to be safe, and could prevent more NTDs. A major educational campaign and modest fortification of grain with folic acid may be the best practical solution.
Adolescent↗
The origin of infrainguinal vein graft stenosis: a prospective study based on duplex surveillance.
PURPOSE: The purpose of this study was to determine the origin of vein graft lesions and their propensity for progression based on prospective duplex surveillance of 135 infrainguinal vein bypasses. METHODS: One hundred sixteen greater saphenous, 13 spliced, five cephalic, and one superficial femoral vein grafts were evaluated by color duplex imaging at surgical procedure, 1 and 6 weeks, 3 and 6 months, and every 3 to 6 months thereafter. Duplex-identified lesions were graded by peak systolic velocity and velocity ratio criteria and were either followed or subjected to revision. RESULTS: Early postoperative duplex surveillance allowed stratification of infrainguinal grafts into two subsets. Of 91 (67%) grafts with normal early scans (at 3 months), only two (2.2%) developed de novo stenoses (at 6 and 8 months) that required revision. Forty-four grafts with abnormal duplex scans had a focal flow abnormality (peak systolic velocity > 150 cm/sec, velocity ratio > 1.5) in the graft body (n = 24) or anastomotic region (n = 20). In 14 grafts the flow abnormality (mean peak systolic velocity = 217 cm/sec, velocity ratio = 2.3) normalized. Ten additional grafts exhibited a moderate, persistent graft stenosis (mean peak systolic velocity 248 cm/sec, velocity ratio = 3.3) that was not repaired. All 20 grafts with lesions that progressed to high-grade stenosis (mean peak systolic velocity = 362 cm/sec, velocity ratio = 7.2) and were revised had a residual flow abnormality confirmed at operation, or it appeared by 6 weeks. In the entire series six (4.4%) grafts failed during the mean 12-month follow-up interval (range 3 to 30 months), 4 with unrepaired defects and two after revision. CONCLUSIONS: Prospective duplex surveillance verified that de novo graft stenosis was uncommon (< 2.2%) after reversed and in situ saphenous vein bypass grafting. Graft stenoses developed at sites of unrepaired defects or early appearing conduit abnormalities. An early appearing duplex focal flow abnormality warranted careful surveillance, because one half of such sites progressed to a high-grade stenosis. Grafts with normal early duplex scans exhibited a low incidence of stenosis development or occlusion, and thus less intense postoperative surveillance can be recommended.
Adult↗
Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study.
OBJECTIVE: To evaluate the role of metabolic control in the progression of diabetic retinopathy during pregnancy. RESEARCH DESIGN AND METHODS: We conducted a prospective cohort study of 155 diabetic women in the Diabetes in Early Pregnancy Study followed from the periconceptional period to 1 month postpartum. Fundus photographs were obtained shortly after conception (95% within 5 weeks of conception) and within 1 month postpartum. Glycosylated hemoglobin was measured weekly during the 1st trimester and monthly thereafter. RESULTS: In the 140 patients who did not have proliferative retinopathy at baseline, progression of retinopathy was seen in 10.3, 21.1, 18.8, and 54.8% of patients with no retinopathy, microaneurysms only, mild nonproliferative retinopathy, and moderate-to-severe nonproliferative retinopathy at baseline, respectively. Proliferative retinopathy developed in 6.3% with mild and 29% with moderate-to-severe baseline retinopathy. Elevated glycosylated hemoglobin at baseline and the magnitude of improvement of glucose control through week 14 were associated with a higher risk of progression of retinopathy (adjusted odds ratio for progression in those with glycohemoglobin > or = 6 SD above the control mean versus those within 2 SD was 2.7; 95% confidence interval was 1.1-7.2; P = 0.039). CONCLUSIONS: The risk for progression of diabetic retinopathy was increased by initial glycosylated hemoglobin elevations as low as 6 SD above the control mean. This increased risk may be due to suboptimal control itself or to the rapid improvement in metabolic control that occurred in early pregnancy. Excellent metabolic control before conception may be required to avoid this increase in risk. Those with moderate-to-severe retinopathy at conception need more careful ophthalmic monitoring, particularly if their diabetes was suboptimally controlled at conception.
Adult↗
A genetic defect in 5,10 methylenetetrahydrofolate reductase in neural tube defects.
It is now well-established that folic acid, taken peri-conceptionally, can reduce the risk of neural tube defects (NTDs). Recent work has demonstrated that an abnormality of homocysteine metabolism is a critical factor. The gene for 5,10 methylenetetrahydrofolate reductase, an enzyme important in homocysteine metabolism, was studied in relation to NTDs. To determine the frequency of the allele for the thermolabile form of the reductase, DNA samples were collected from people with NTDs, parents of people with NTDs, and normal controls. Of 82 people with NTDs, 15 (18.3%) were homozygous for the abnormal, thermolabile allele. This was significantly higher (p = 0.01) than the rate of 6.1% in the control population (odds ratio 3.47, 95% CI 1.28-9.41). This is the first specific genetic abnormality to be identified in NTDs. It explains the association between some NTDs and elevated homocysteine, given that the reductase is important in homocysteine metabolism. It also explains how folic acid supplementation prevents some NTDs, by overcoming a partial block in the conversion of 5,10 methylenetetrahydrofolate to 5 methyltetrahydrofolate. Genetic screening could identify women who will require folic acid supplements to reduce their risk of having a child with an NTD.
Case-Control Studies↗
Educational attainment in long-term survivors of childhood acute lymphoblastic leukemia.
OBJECTIVE: To determine the impact of treatment on scholastic performance in the first cohort of survivors of childhood acute lymphoblastic leukemia who are old enough to have completed their educational experience. DESIGN: Retrospective cohort study. SETTING: Twenty-three institutions in the Childrens Cancer Group. SUBJECTS: A total of 593 adult survivors of childhood acute lymphoblastic leukemia and 409 sibling controls. OUTCOME MEASURES: Enrollment in special programs, grades during high school, graduation from high school, college admission, and college graduation. RESULTS: After diagnosis, survivors were more likely than their sibling controls to enter a special education (relative risk [RR] = 3.4; P < .01) or a learning disabled (RR = 3.6; P < .01) program, while just as likely to enter gifted and talented programs (RR = 1.0). The risk associated with special education and learning disabled programs increased with increasing dose of cranial radiotherapy. Despite these problems, survivors generally had the same probability as their siblings of finishing high school, entering college, and earning a bachelor's degree. However, survivors treated with 24 Gy and those diagnosed before 6 years of age were less likely to enter college (RR = 0.67 and 0.6, respectively; P < .01). CONCLUSIONS: This large study demonstrates that childhood acute lymphoblastic leukemia survivors have a greater likelihood of being placed in special education or learning disabled programs than their siblings, but that most are able to overcome these problems. Dose of cranial radiotherapy and age at diagnosis are the most important education-related risk factors.
Adolescent↗
The juxtarenal abdominal aortic aneurysm. A more common problem than previously realized?
OBJECTIVE: To determine the incidence and treatment outcome of juxtarenal infrarenal aneurysmectomy in a vascular practice minimally biased by tertiary referral. DESIGN: A 5-year retrospective review of all aortic operations from our vascular registry was performed, and a case series of juxtarenal aneurysmectomies was analyzed. PATIENTS: Of 174 infrarenal aortic aneurysmectomies performed, 27 (15.5%) (95% confidence interval, 10.5% to 21.8%) involved the juxtarenal aorta. INTERVENTIONS: Juxtarenal involvement was unsuspected but found by aortography in 25 (93%) of 27 cases. Resection was performed transabdominally in 20 cases (74%) and retroperitoneally in seven cases (26%). MAIN OUTCOME MEASURES: Incidence, operative technique, morbidity, and mortality were analyzed and compared with those of historical controls. RESULTS: The incidence of juxtarenal aneurysmectomy was 15.5%. No operative deaths occurred, but there was a 19% incidence of surgical morbidity (including a 7% incidence of transient renal failure). The late survival rate was 89% (follow-up, 1 to 53 months; mean, 18 months). CONCLUSIONS: Juxtarenal aortic aneurysms are not uncommon. Successful management is possible, even outside the large referral center.
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