Complex coronary artery stent placement is one of your particular skills and interests. Dr. Anton Titov, MD. What constitutes complex coronary artery stent situation? How to treat complex coronary artery disease patients? Dr. Jeffrey Popma, MD. The idea of complex coronary artery intervention has been evolved into a new word called CHIP. It is Complex High-risk Interventional Procedures. That has been termed CHIP by a number of people. Dr. Ajay Kirtane at Columbia University certainly is high on the list of that. The idea is that we look at calcified vessels. Dr. Jeffrey Popma, MD. We treat Total coronary artery occlusions, very diffuse coronary disease. We treat coronary artery blockages at over 20 or 30 millimeters in length. Dr. Anton Titov, MD. Long coronary artery blockages require multiple coronary stents. Some patients with coronary artery disease are not candidates for surgical CABG operations. There are patients with very low left ventricular ejection fractions. It turns out that CHIP categories are about 20% of the coronary artery stent placement work that we do. Dr. Jeffrey Popma, MD. It takes another skill set to do complex coronary artery disease treatment. It is much more challenging. It is much more diverse than what we typically had to do in coronary artery stenting. We used plain old balloon angioplasty or single lesion coronary artery stent implantation. Dr. Jeffrey Popma, MD. There are several devices that we use in addition to our regular balloons, wires and stents. This is Complex coronary artery stent placement. We might use a removable left ventricular assist device. It is the Impella device to support the patient's heart muscle function during the CHIP procedure. Dr. Jeffrey Popma, MD. For very calcified coronary artery lesions we might use rotational atherectomy or orbital atherectomy. Dr. Anton Titov, MD. This breaks apart the calcium before we actually put the coronary artery stents in. We may use a variety of techniques for treatment of complex total coronary artery occlusions and for chronic total coronary artery occlusions. We may use a variety of antegrade techniques and retrograde techniques. We have developed a specialty team with Dr. Bobby Yeh, Dr. Duane Pinto, and Dr. Hector Tamez here at our institution. But most institutions will have some cardiothoracic experts. They really dedicate themselves to being able to try to re-canalize coronary vessels that typically wouldn't be able to be approached before. Dr. Jeffrey Popma, MD. We can take care of coronary artery disease patients who just don't have good surgical options. Yet we have to do multiple coronary artery stents. We have to place stents into multiple coronary vessels. They are the hardest cases. Dr. Anton Titov, MD. There's no question, you are most tired at the end of CHIP case. You are more tired than with a regular diagnostic coronary artery catheterization in someone who's got unstable angina. Dr. Jeffrey Popma, MD. But Complex coronary artery stent placement can also be the most rewarding cases. Dr. Anton Titov, MD. Because those patients have oftentimes have very few treatment options left. Complex coronary artery intervention is called CHIP. Complex High-risk Interventional Procedures. Many patients with coronary artery disease now require multiple lengthy coronary artery stent placement.