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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).

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