<International Circulation>: Would you like to introduce the complications during chronic total occlusion (CTO) treatment.  How can you prevent and treat those complications?

Prof. Takahiko Suzuki: When CTO percutaneous coronary intervention (PCI) is successful， patients are very happy because they may evade bypass surgery.  However， when complication occurs， they can cause significant morbidity and mortality so it is important to be aware of several complications during CTO treatment.  Severe life-threatening complications include coronary artery perforation， pericardial tamponade， and arterial dissection.  If the operator manipulates the guidewire and performs the procedure well， in most cases complications can be avoided.  However， in very old， calcified， and long CTOs， it becomes difficult to cross the guidewire through the lesion.  In these cases， crossing the CTO lesion may be accomplished by using a stiffer guidewire， however using a stiffer guidewire with a hard tip may lead to penetration through the coronary artery resulting in perforation or dissection.  Therefore， it is important to handle the guidewire gently and to become skilled in performing the procedure， which will limit complications.

Knowing how to manage coronary artery perforation is important.  In most cases prolonged balloon inflation with heparin reversal (intravenous administration of protamine) should be sufficient to control the bleed.  It is important to be aware that in some cases， delayed cardiac tamponade can occur hours post-procedure with the patient developing hypotension.  Quick treatment is very important in this situation and urgent pericardiocentesis is required.  In most cases pericardiocentesis along with prolonged balloon dilatation at the perforation site， hemostasis can be achieved.  We have had two patients with perforations， in which it was difficult to achieved hemostasis， and were referred to emergent bypass surgery.

<International Circulation>: What is your opinion on bifurcation lesion treatment?  Do you prefer to perform any special strategy?  Would you like to give us some tips?

Prof. Takahiko Suzuki: The two main strategies in the treatment of coronary artery bifurcation lesions are the complex stenting strategy and the simple stenting strategy.  The simple stenting strategy involves stenting the main vessel with optional stenting of the side branch whereas the complex stenting strategy involves stenting both the main vessel and the side branch.  In my opinion， no complex stenting is very important in the treatment of coronary artery bifurcation lesions.  Keep it simple， simple is best.  If the simple stenting strategy gives an incomplete result， when it does not achieve an optimal result， then provisional complex stenting， where the main branch is stented with provisional stenting of the side branch， may be necessary.  In most cases， the simple stenting strategy is sufficient to manage bifurcation lesions.  We sometimes use debulking as another technique to improve the outcome of treating bifurcation lesions.  After debulking the plaque， especially CTO lesions， we can then use the simple stenting strategy and get a very good result.