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Richard D Fessler

Publications and source records attributed to Richard D Fessler.

9 recordsLinked to original sources
PubMed2005

Resident duty hours reform: results of a national survey of the program directors and residents in neurosurgery training programs.

OBJECTIVE: The new Accreditation Council for Graduate Medical Education (ACGME) requirements regarding resident work hours have been implemented since July 2003. Neurological surgery training programs have been especially affected because of the limited number of residency positions and the residents' long duty hours. The perceptions of program directors and residents may provide important insight into the evolution of new guidelines for improvement of resident training. METHODS: We conducted a nationwide survey of 93 program directors and 617 residents to characterize their perceptions regarding the changes in their training programs related to compliance with the ACGME requirements. The survey was conducted from July through September 2003 using electronic mail. RESULTS: The response rates were 45% and 23% among the program directors and residents, respectively. Most programs offered one (37%) or two (38%) resident training positions per year. Although 92% of programs had implemented the ACGME work hours requirements before or since July 2003, 8% had not yet implemented these guidelines. Sixty-eight percent of program directors indicated employment of ancillary health care professionals to fulfill the ACGME duty hours reform; 84% (95% confidence interval [CI], 64-94%) thought that this practice has not limited the residents' clinical experience. Eleven percent of respondents (18 of 164 respondents) who provided Level I trauma coverage were unable to maintain compliance with the ACGME guidelines. Ninety-three percent (95% CI, 89-96%) of all respondents thought that the work hour reform has had a negative impact on the continuity of patient care. Fifty-five percent (95% CI, 46-63%) of the residents and only 33% (95% CI, 20-50%) of the program directors thought that the ACGME requirements are likely to result in improved American Board of Neurological Surgery written test scores. Twenty-nine percent (95% CI, 22-37%) of the residents and 17% (95% CI, 8-32%) of the program directors thought that resident attendance at national conferences would increase. Similarly, although 46% (95% CI, 37-54%) of residents perceived that these work hour limitations would facilitate residents' research/publication-related activities, only 21% (95% CI, 11-37%) of program directors agreed. Forty-one percent (95% CI, 33-49%) of the residents and 74% (95% CI, 58-86%) of the program directors perceived that the chief residents operate on fewer complex cases since the institution of the ACGME duty hour guidelines. Seventy-five percent of residents think they are less familiar with their patients. Overall, 61% (95% CI, 53-69%) of the residents and 79% (95% CI, 63-89%) of the program directors noted that the ACGME guidelines have had a negative effect on their training programs. CONCLUSION: On the basis of their early experience, the majority of the residents and program directors think that the ACGME duty hour guidelines have had an adverse effect on continuity of patient care and resident training. The effects of these guidelines on neurosurgery programs should be carefully monitored, because more sophisticated solutions may be needed to address house staff fatigue. Strategies to enhance the educational content of the residents' work hours and to preserve continuity of patient care are necessary.

Data Collection↗
PubMed2005

A triple bifurcation aneurysm model for evaluating complex endovascular therapies in dogs.

OBJECT: Animal aneurysm models are required for the study of the hemodynamics and pathophysiology of intracranial aneurysms in humans and so that experimental treatments can be tested prior to clinical trials. The authors developed a canine model that consistently produces up to three bifurcation aneurysms similar in morphological features and hemodynamics to human intracranial aneurysms. METHODS: In 10 mongrel dogs, a harvested segment of the external jugular vein was anastamosed to an external carotid artery (CA)-lingual artery bifurcation arteriotomy site to create a lateral bifurcation aneurysm. The surgery was repeated on the contralateral side in each animal to form a second lateral bifurcation aneurysm and, in five dogs, a CA-CA crossover anastomosis was also performed to create a terminal bifurcation aneurysm. Nineteen of 20 lateral bifurcation aneurysms were confirmed in 10 dogs by diagnostic angiography 7 to 14 days after surgery. Aneurysm fundus-to-neck ratios ranged from 1 to 2, depending on the size of the arteriotomy. The terminal bifurcation aneurysms were confirmed in all five dogs by diagnostic angiography 7 to 14 days after the procedure. The authors later tested endovascular techniques for embolizing the aneurysms. CONCLUSIONS: Three bifurcation aneurysms of sufficient size for endovascular access can be created in a reproducible fashion in the same animal. This model is useful for studying complex endovascular procedures in aneurysms that mimic the human condition and for testing new devices and techniques.

Anastomosis, Surgical↗
PubMed2004

Basilar artery to bilateral posterior cerebral artery 'Y stenting' for endovascular reconstruction of wide-necked basilar apex aneurysms: report of three cases.

Endovascular reconstruction of basilar artery (BA) apex aneurysms has been augmented by adjunctive techniques such as balloon and stent assistance. We present three cases of a wide-necked BA apex aneurysm involving the bilateral P1 segments of both posterior cerebral arteries (PCAs) treated by placement of BA to PCA stents bilaterally in a 'Y' configuration to reconstruct the BA apex for effective coil embolization. Three patients (aged 70, 65 and 37 years) with wide-necked basilar artery aneurysms presented for endovascular treatment. All aneurysms had necks that involved the bilateral P1 segments. Each patient was deemed an appropriate candidate for endovascular reconstruction. Patients were pretreated with clopidogrel (75 mg) and aspirin (325 mg) each day for 3 days prior to the procedure. Following induction of general anesthesia, access to the right femoral artery was obtained by placement of a 6F sheath. Intravenous heparin was administered to achieve an activated coagulation time (ACT) of approximately 300 seconds. A 6F guide catheter was placed within the left vertebral artery (VA) in two patients, the right VA in a third. Utilizing over-the-wire (OTW) technique, a microcatheter was advanced into the left P2-P3 junction of the PCA. A 300-cm 0.014-inch microwire was passed through the microcatheter into the distal PCA and the microcatheter was removed. In each case, two neuroform stents were prepared (SMART Therapeutics Inc., San Leandro, CA) and advanced OTW into the PCA with the most acute angle relative to the BA. The initial stent placed was 20 mm in length and was deployed from the P1 segment into the BA. The microwire was pulled retrograde into the BA apex, then advanced though the stent struts and into the right PCA. A second stent, 15 mm in length, was advanced OTW through the struts of the previously placed stent. It was then deployed from the P1 into the BA where it overlapped the first stent, resulting in a stent-in-stent 'Y' configuration at the BA apex. A microcatheter was advanced OTW into the BA apex aneurysm and coil embolization proceeded in the usual fashion. Following the procedure, each patient was maintained in the neurosurgical intensive care unit (NICU). All remained neurologically intact. The two elderly patients were discharged to home the morning following the procedure. The third patient suffered an upper GI bleed and was treated an additional 3 days in hospital. Oral clopidogrel (75 mg by mouth) and aspirin (325 mg by mouth) were continued daily for 4 weeks. The 'Y' stent configuration for reconstruction of the BA apex is a safe effective technique in patients with wide-necked BA aneurysms.

Adult↗
PubMed2004

Direct percutaneous carotid artery stenting with distal protection: technical case report.

We describe the technique of percutaneous carotid artery stent placement with distal protection in a patient in whom marked innominate artery ectasia prevented transfemoral access to the right common carotid artery. After induction of general anesthesia, ultrasound was used to guide direct puncture of the common carotid artery followed by the introduction of a 5 French sheath. A GuardWire distal protection balloon (Medtronic, Santa Rosa, CA) was placed distal to the lesion and deployed at nominal diameter. A balloon-expandable stent was deployed without difficulty. Following stent placement, angiography demonstrated improved flow in the entire right carotid artery territory. There were no complications related to cervical soft tissue damage or clinical embolism. The patient tolerated the procedure well and was discharged in 24 hours. Direct carotid access is acceptable in select patients in whom a transfemoral, brachial, or transradial approach is technically difficult. The use of distal cerebral protection devices may reduce cerebral embolism associated with these procedures.

Aged↗
PubMed2003

Regional brain cooling induced by vascular saline infusion into ischemic territory reduces brain inflammation in stroke.

The neuroprotective effect of hypothermia has long been recognized. Use of hypothermia for stroke therapy, which is currently being induced by whole body surface cooling, has been largely limited because of management problems and severe side effects (i.e., pneumonia). Our recent studies have demonstrated the significant therapeutic value of local brain cooling in the ischemic territory prior to reperfusion in stroke. The goal of this study was to determine if cerebral local cooling infusion could reduce stroke-mediated brain injury by inhibiting inflammatory responses. A hollow filament was used to block the middle cerebral artery (MCA) for 3 hours, and then to locally infuse the ischemic territory with 6 ml cold saline (20 degrees C) for 10 min prior to 48-h reperfusion. This cold saline infusion significantly ( P<0.01) reduced temperature of the MCA supplied territory (in cerebral cortex from 37.2+/-0.1 degrees C to 33.4+/-0.4 degrees C, in striatum from 37.5+/-0.2 degrees C to 33.9+/-0.4 degrees C), with the hypothermia remaining for at least 45 min after reperfusion. Consequently, significant ( P<0.01) reductions in endothelial expression of intracellular adhesion molecule-1 (ICAM-1), the key step for inflammatory progress, as well as leukocyte infiltration, were evident in both cortex and striatum after reperfusion. As a control, ischemic rats received the same amount of cold saline systemically through a femoral artery. A mild hypothermia was induced in the cerebral cortex (35.3+/-0.2 degrees C) but not in the striatum (36.8+/-0.2 degrees C). The reduced cortical temperature returned to normal within 5 min. Brain temperature in ischemic rats perfused locally with saline at 37 degrees C remained normal. Intensive expression of ICAM-1 and accumulation of leukocytes was observed in ischemic control groups without brain cooling infusion. In conclusion, brain hypothermia induced by local pre-reperfusion infusion ameliorated brain inflammation from stroke.

Analysis of Variance↗
PubMed2002

Carotid angioplasty and stent placement: a prospective analysis of perioperative complications and impact of intravenously administered abciximab.

OBJECTIVE: To determine the frequency of perioperative complications since the introduction of abciximab, we prospectively evaluated our experience in a consecutive series of patients undergoing carotid angioplasty and stent placement (CAS). CAS has been introduced recently for treatment of carotid artery stenosis. A major limitation to this modality is the risk of perioperative thromboembolic and ischemic events. To reduce the risk of ischemic complications, abciximab, a platelet glycoprotein IIb/IIIa receptor inhibitor, has been introduced as adjunctive treatment for high-risk patients. METHODS: Each patient was evaluated by a neurologist before, immediately after, and 24 hours after CAS for identification and classification of new neurological deficits. Bleeding events or other complications during hospitalization were recorded. Bleeding complications were classified as major (hemoglobin decrease,g5 g/dl), minor (hemoglobin decrease, 3-5 g/dl), or insignificant. Abciximab was administered intravenously as a single bolus (0.25 mg/kg) and then via infusion (10 microg/min) for 12 hours as an adjunct to CAS in patients considered to be at high risk for thromboembolic events owing to recent ischemic symptoms and/or complex lesion morphology. RESULTS: Intravenously administered abciximab was used in 37 patients (mean age, 70 yr; 21 patients were men) as an adjunct to high-risk CAS. Thirty-three other patients underwent CAS performed with standard intraprocedural heparinization (mean age, 69 yr; 17 patients were men). Minor ischemic strokes were observed in 1 of 37 abciximab-treated patients and in 4 of 33 heparin-treated patients. No major ischemic strokes were observed in either group. Transient neurological deficits were observed in nine patients in the abciximab-treated group and in one patient in the heparin-treated group. Transient neurological deficits in abciximab-treated patients were mainly related to hemodynamic factors (associated with balloon inflation in two patients and with hypotension in another two patients) or occurred after completion of infusion (in three patients). Minor bleeding complications were observed in three patients who received abciximab and in four patients who received standard heparinization. Major bleeding complications were observed in four patients from each group. Two patients who received abciximab developed intracerebral hemorrhages; one hemorrhage was fatal. CONCLUSION: The frequency of ischemic stroke in high-risk patients (3%) with the use of intravenously administered abciximab was lower, but not significantly so, than rates observed in lower-risk patients (12%), although the benefit was lost because of the high rate of intracranial hemorrhages (5%). Further efforts are required to determine appropriate selection criteria for use of intravenously administered abciximab and the effect of other strategies that involve distal protection devices.

Abciximab↗
PubMed2002

New techniques in cerebral imaging.

This article presents a review of the current techniques in Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) that enhance the usefulness of these tests for the diagnosis of cerebral disease. We were able to analyze concepts and definitions and give a comparative description for each test studied including Multidetector/Perfusion CT, Xenon CT, CT-Angiogram, MRI-Perfusion, MRI-Diffusion, MRI-Spectroscopy, MRI CSF Flow, Functional MRI studies and Cerebral Angiography.

Brain Diseases↗
PubMed2002

Transradial cerebral angiography: an alternative route.

INTRODUCTION: The transradial approach has been well described for arteriography of the coronary vessels. To assess the safety and success rate of the transradial approach for three-vessel or four-vessel diagnostic cerebral arteriography, we reviewed the experience at our institution and compared our complication rates with those found in the literature for transfemoral cerebral angiography and transradial coronary angiography. METHODS: We reviewed the electronic medical records of 129 consecutive patients in whom 132 cerebral angiographic studies were performed by use of a transradial approach between December 1999 and June 2001. A total of 54 selective catheterizations were performed, of which 39 were of the vertebral artery, 11 of the internal carotid artery, and 4 of the external carotid artery. Records were reviewed for periprocedural and delayed complications, indications for diagnostic angiography, and requirement of conversion to a femoral approach. Records were reviewed prospectively for the first 55 procedures and retrospectively for the next 77 procedures. RESULTS: The mean time to initial clinical follow-up was 1.5 months (median, 0.5 mo). The combined rate of periprocedural and delayed complications was 9%, and there were no major complications. Minor periprocedural complications included transient radial artery spasm (four patients), failure to access the brachial artery (two patients), severe pain (one patient), skin desquamation (one patient), and hematoma (one patient). There were no major complications. At the time of follow-up evaluation, these patients were without deficits related to cannulation of the radial artery. CONCLUSION: The transradial approach for cerebral angiography is a safe alternative to the transfemoral route. After transradial cerebral angiography, patients require a shorter observation period and are not restricted to bed rest. As technological developments generate smaller, more pliable endovascular surgical devices, future endovascular surgery may be performed transradially.

Adolescent↗