Protected percutaneous coronary intervention – a new road for success in treating complex patients

Advances in material and procedural techniques have improved the ability to perform percutaneous coronary intervention (PCI) in challenging and complex anatomies. Yet, technical feasibility of PCI is not the only issue in the treatment of complex coronary artery disease, which may be approached by surgery or by PCI. Complexity of the patient is the other, and is probably even more important. The SYNTAX trial has shown that patients with low anatomical complexity can be treated safely by PCI, while patients with high anatomical complexity should be treated by surgery [1, 2]. However, this does not hold true for complex patients with a high perioperative risk, who are frequently encountered in clinical practice today. Such patients present not only with complex coronary anatomies (e.g. left main stenosis, multivessel disease, last remaining vessel), but also with hemodynamic impairment (e.g. impaired left ventricular function, hemodynamic instability) and complex comorbidities (e.g. recent myocardial infarction, congestive heart failure, diabetes, chronic obstructive pulmonary disease, renal failure, valvular heart disease, increased age). Hence, decision making in general has to be carefully based on the anatomical risk (i.e. the complexity of the coronary artery disease) on one hand and on the surgical, perioperative risk on the other (Figures 1 A, B).
In routine clinical practice, high-risk patients with high-risk anatomies are often judged as inoperable or at too high risk for surgery by the heart team and referred for interventional treatment by PCI. But how can the interventionalist ensure a good procedural outcome in patients presenting with severe impairment of left ventricular function and left main disease? Of note, these were exactly the patients who were treated in the article of Dudek et al. presented in the current issues of Advances in Interventional Cardiology [3].
Current guidelines suggest that elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable in carefully selected high-risk patients [4, 5]. Though somewhat general, this recommendation contains the principle of so-called protected PCIs.
Coronary ischemia as a result of repeated temporary coronary occlusions (during ballon-angioplasty and stenting) can transiently worsen during PCI, which may lead to peri- and postprocedural adverse events. This is of utmost importance in patients with left ventricular dysfunction and...


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