Robert Ward Pulliam

Lancaster General Hospital, Lancaster, Pennsylvania, United States

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Publications (10)26.03 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The need to add a lead(s) despite subclavian/innominate obstruction is increasing. Subclavian venoplasty may be a good alternative to the commonly employed options; however, there are few reports in the literature, and all are by interventional radiologists. To describe the procedural details, results and safety of venoplasty by implanting physicians in a large group of consecutive patients. Safety, lead function and success were established from review of the procedure reports and clinical complications in 373 consecutive venoplasty patients from 1999-2010. Procedural details were obtained by review of the angiograms (venograms) and procedural flow charts of 152 consecutive patients from 2004-2007. Venoplasty was successful in 371 of 373 patients without damage to the existing leads and without clinical complications. Total angiographic occlusion was demonstrated in 65% of cases by peripheral venogram, but in only 20% of cases by contrast injection at the site of obstruction; 86% were crossed with a hydrophilic wire. Microdissection and excimer laser were used to cross three of the four wire-refractory occlusions. Obstruction was both central and peripheral in 22.1% of cases and central only in 17%. The time required to cross the obstruction and perform venoplasty was 13 ± 21 minutes. A noncompliant balloon was successful in most, but an ultranoncompliant balloon was required in 13% of cases. Contrast extravasation was common during crossing of a total obstruction and also was observed with balloon rupture on three occasions, but was not clinically significant. Subclavian venoplasty is a safe, practical lead-management option that can be used by implanting physicians.
    Heart rhythm: the official journal of the Heart Rhythm Society 12/2010; 8(4):526-33. · 4.56 Impact Factor
  • Seth J Worley, Douglas C Gohn, Robert W Pulliam
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    ABSTRACT: Ideally, new leads are placed via the axillary/cephalic vein on the same side as the initial implant; however, 3.6% to 9% of patients have chronic total subclavian/innominate occlusion. In most cases, a wire can be manipulated across the occlusion and venoplasty safely performed. Occasionally, a wire will not cross, and additional tools are required. The purpose of this study was to evaluate our experience with an excimer laser catheter used to cross wire-refractory chronic total subclavian/innominate occlusion in 12 patients. We first used the laser to successfully cross a lead-related chronic total occlusion that did not yield to either a wire or microdissection. We subsequently used the laser for 11 additional wire-refractory occlusions. We reviewed the implant reports, hospital records, and videos of each case. The occlusions were successfully crossed and a wire placed for venoplasty in 11 of 12 cases by one of three implanting physicians. No complications occurred, and the existing leads sustained no damage. Although the safety of the procedure remains uncertain, if directions are followed and are precautions heeded, physicians with training and experience in venoplasty and laser lead extraction can learn this technique, which provides an important option for adding a lead to an existing device when the ipsilateral access vein is occluded.
    Heart rhythm: the official journal of the Heart Rhythm Society 01/2010; 7(5):634-8. · 4.56 Impact Factor
  • Seth J Worley, Douglas C Gohn, Robert W Pulliam
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    ABSTRACT: Venous anatomy frequently impairs placement of the left ventricular (LV) lead. In some cases, the wire will not advance into the vein and in others wire position is lost as the lead is advanced. This article describes how a commonly available goose neck snare is used to gain access to the distal end of the wire as it re-enters the coronary sinus retrograde via collaterals through an adjacent vein. The snare is advanced into the coronary sinus through the same catheter as the wire. The snare opens perpendicular to the long axis of the coronary sinus due to which the wire must pass through the open loop, provided the diameter of the snare is approximately the same as the coronary sinus. Thus no time-consuming manipulation of the snare is required. With access to both ends of the wire the vein is approached either retrograde (over the distal end) or antegrade (over the proximal end) while the other end of the wire is secured by the operator. Gaining control of both ends of the wire with a snare is another example of adapting interventional techniques for the device implantation. Unlike venoplasty, the snare does not evoke credentialing concerns and can be easily implemented by most implanting physicians.
    Pacing and Clinical Electrophysiology 10/2009; 32(12):1577-81. · 1.75 Impact Factor
  • Seth J Worley, Douglas C Gohn, Robert W Pulliam
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    ABSTRACT: This report describes two patients who underwent a second attempt at cardiac resynchronization therapy (CRT) in the setting of a severe stenosis in the lateral coronary vein that prevented passage of a left ventricular lead. Both stenoses were unresponsive to standard noncompliant balloon dilatation but were successfully treated with the addition of a second stiff angioplasty wire beside the noncompliant balloon. Venoplasty with the addition of a side wire beside the balloon should be considered for resistant coronary vein stenosis encountered during CRT device implantation.
    Pacing and Clinical Electrophysiology 12/2008; 31(11):1503-5. · 1.75 Impact Factor
  • Seth J Worley, Douglas C Gohn, Robert W Pulliam
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    ABSTRACT: Coronary vein rupture is a potential complication of venoplasty for LV lead placement. Vein rupture in a patient with a virgin pericardium would be anticipated to have a profound hemodynamic impact from bleeding into the pericardial space. This report describes an elderly woman with a virgin pericardial space who underwent cardiac resynchronization therapy (CRT). Venoplasty of a lead limiting venous stenosis was performed on the lateral coronary vein. The stenosis was unresponsive to a standard noncompliant balloon with side wire. When the inflation pressure was increased beyond the rated burst pressure the balloon ruptured, perforating the vein. We describe our experience in successfully placing the left ventricular lead safely despite the problems arising from these circumstances.
    Pacing and Clinical Electrophysiology 08/2008; 31(7):904-7. · 1.75 Impact Factor
  • Seth J Worley, Douglas C Gohn, Robert W Pulliam
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    ABSTRACT: Venoplasty allows the addition or replacement of leads despite subtotal or total subclavian occlusion. The threshold of the LV pacing lead implanted for biventricular pacing over a period of 18 months increased to greater than 5 V. A pre implant venogram revealed total subclavian occlusion. Venous access was maintained by extraction of the 4 F LV lead over a wire. Subsequently the sheath would not advance despite 6mm balloon inflation to 30 atm with no residual waist. A wire was placed beside the balloon and the balloon was reinflated. The subclavian obstruction was eliminated without damage to the existing leads. The obstruction formed by the fibrous track around an extracted lead may persist despite what appears to be successful balloon dilation. Inflation with a wire beside the balloon increases the effect eliminating the resistant obstruction without damaging the leads.
    Journal of Interventional Cardiac Electrophysiology 06/2008; 23(2):135-7. · 1.39 Impact Factor
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    ABSTRACT: A persistent left superior vena cava markedly increases the size of the coronary sinus (CS), which can increase the difficulty of left ventricular (LV) lead placement in patients receiving cardiac resynchronization therapy (CRT). We present a case where the entire superior vena cava drains into the coronary sinus, creating a massive CS. We also describe an interventional approach to LV lead implantation utilizing a combination of delivery systems from different vendors.
    Pacing and Clinical Electrophysiology 05/2008; 31(4):506-8. · 1.75 Impact Factor
  • Heart Rhythm 04/2008; 5(3):469-71. · 5.05 Impact Factor
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    ABSTRACT: Patients with existing internal cardioverter defibrillators (ICDs) often require upgrading to a biventricular ICD for treatment of congestive heart failure. Placement of a left ventricular (LV) lead can be technically challenging in the best of circumstances. A subclavian vein stenosis or occlusion related to previously placed leads adds a major obstacle to a successful implant. We report a technique to implant an LV lead from the same side as the existing ICD system despite failed microdissection of a complete occlusion of the subclavian vein.
    Pacing and Clinical Electrophysiology 01/2008; 30(12):1562-5. · 1.75 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Patients with existing internal cardioverter defibrillators (ICDs) often require upgrading to a biventricular ICD for treatment of congestive heart failure (CHF). Placement of a left ventricular (LV) lead can be technically challenging in the best of circumstances. A subclavian vein stenosis or occlusion related to previously placed leads adds a major obstacle to a successful implant. We report a technique of implanting an LV lead from the same side as the existing ICD system despite complete occlusion of the subclavian vein.
    Pacing and Clinical Electrophysiology 11/2007; 30(10):1290-3. · 1.75 Impact Factor