The "Bundle Wire" Technique: A Novel Approach to Cannulating Challenging Target Vessels Using Multiple Fine Atraumatic Guidewires That Together Serve as a Stiff Guidewire

PURPOSE

To present a novel technique that enables safe and effective cannulation of target vessels with challenging anatomy during fenestrated/branched endovascular aortic repair (F/B-EVAR).

TECHNIQUE

Following deployment of the F/B-EVAR endograft, the target vessels (TVs) are cannulated. The bundle wire technique provides a solution to challenging TVs and uses multiple fine atraumatic guidewires that together serve as a stiff guidewire. The technique can be executed in 2 ways using: (1) one 0.018 inch and one 0.014 inch guidewire or (2) three 0.014 inch guidewires. We demonstrate the technique in a case of a complex abdominal aortic aneurysm treated using branched EVAR in which the left renal artery with severe ostial stenosis was catheterized using the bundle wire technique.

CONCLUSIONS

The bundle wire technique offers a technically feasible and economically viable solution for facilitating catheter and bridging stent delivery in anatomically challenging TVs during F/B-EVAR. It is a useful addition to the therapeutic armamentarium available to physicians for accessing demanding TVs.

Prevalence and burden of atopic dermatitis involving the head, neck, face, and hand: A cross sectional study from the TARGET-DERM AD cohort

BACKGROUND

Atopic dermatitis (AD) is severely burdensome, and there has been poor characterization of any differences in impact based on the area affected.

OBJECTIVE

To estimate the prevalence and HRQoL impact of head/face/neck/hand (HFNH) involvement among patients with moderate-to-severe atopic dermatitis.

METHODS

All TARGET-DERM AD registry patients with moderate/severe Investigator Global Assessment (vIGA-AD) were assessed using the Patient Oriented SCORing Atopic Dermatitis, Patient Oriented Eczema Measure (POEM) and the (Children's) Dermatology Life Quality Index ((C)DLQI).

RESULTS

541 participants met the criteria (75.0% adults) and 84% (N = 453) reported HFNH involvement. HFNH and non-HFNH involved participants had similar characteristics; 55.2% female and 46.9% White. Compared to the non-HFNH involved, the involved had severe vIGA-AD (28.5% vs 16.3%, P = .02) and higher median body surface area affected (15% vs 10%, P ≤ .01) and were twice as likely to have higher (C)DLQI and POEM scores.

LIMITATIONS

This was an analysis of real-world and patient reported outcome data.

CONCLUSION

Real-world HFNH involved AD patients were associated with significantly worse quality of life, POEM/(C)DLQI, and more severe disease. Detailed assessments of specific areas affected by AD are needed to personalize treatment.

Checkpoint inhibitor use in two heart transplant patients with metastatic melanoma and review of high-risk populations

Due to the unique side-effect profile of immune checkpoint inhibitors (ICIs), groups of patients deemed to be at high risk of complications were excluded from trials that proved the efficacy and safety of these agents in patients with various malignancies. Among these excluded patients were those with prior solid organ transplantation, chronic viral infections and pre-existing autoimmune diseases including paraneoplastic syndromes. We present follow-up on a patient from a previously published case report with an orthotopic heart transplantation who was treated with both cytotoxic T-lymphocyte antigen 4 and PD-1 inhibition safely, without organ rejection. Additionally, we describe the case of a patient with a cardiac allograft who also did not experience organ rejection after treatment with pembrolizumab. Through smaller trials, retrospective analyses, case series and individual case reports, we are accumulating initial data on how these agents are tolerated by the aforementioned groups. Our survey of the literature has found more evidence of organ transplant rejection in patients treated with PD-1 inhibitors than those treated with inhibitors of cytotoxic T-lymphocyte antigen 4. Patients with chronic viral infections, especially hepatitis C, seem to have little to no risk of treatment-related increase in serum RNA levels. The literature contains few documented cases of devastating exacerbations of pre-existing autoimmune disease during treatment with ICIs, and flares seem to be easily controlled by immunosuppression in the vast majority of cases. Last, several cases allude to a promising role for disease-specific antibodies and other serum biomarkers in identifying patients at high risk of developing certain immune-related adverse events, detecting subclinical immune-related adverse event onset, and monitoring treatment response to immunosuppressive therapy in patients treated with ICIs. Though these excluded populations have not been well studied in randomized placebo-controlled trials, we may be able to learn and derive hypotheses from the existing observational data in the literature.

Delayed Management of Unrecognized Bilateral Temporomandibular Joint Dislocation: A Case Report

Temporomandibular joint (TMJ) dislocation is a common occurrence, but diagnosis can be missed if patients do not complain. Delayed presentation complicates the management of a straightforward reduction. We present a case of a 24-year-old man who had bilateral TMJ dislocation of unknown duration after motor vehicle accident. The accident left him bedridden with speech difficulty. He was totally dependent on Ryles' and percutaneous endoscopic gastrotomy tubes for feeding. Computed tomography revealed dislocation of condyles anterior to articular eminences. The bilateral TMJ dislocations were reduced surgically via bicoronal with preauricular extension approaches. However, the surgery was challenging due to tissue changes around the joint accompanied by masticatory muscles atrophy. Postoperatively, he was placed on intermaxillary fixation for 2 weeks followed by elastics training. Three months later, the patient's mastication returned completely to function. Delayed management of bilateral TMJ dislocation is undoubtedly challenging and somewhat frustrating; nevertheless, we manage to achieve satisfactory outcome in improving the patient's quality of life.