High Risk Percutaneous Coronary Intervention

High risk percutaneous coronary intervention (HR-PCI) encompasses a wide range of risk factors present in the modern catheterization lab. Patients categorized as HR-PCI typically have lower physiological tolerance for revascularization given their inherent anatomical, hemodynamic, and clinical characteristics. However, they represent a patient cohort that may more greatly benefit from complete revascularization. Mechanical circulatory support has been developed as a means to reduce the risk associated with “high-risk” PCI. Factors relevant to patient categorization can be broken down into three key areas: (i) anatomical criteria, (ii) hemodynamic criteria, and (iii) clinical/comorbid criteria. To date, few cardiovascular guidelines have outlined a clear definition of HR-PCI. Clinical evidence is lacking to accurately guide risk stratification, define choice of mechanical circulatory support (MCS), and influence outcomes. This chapter outlines the risk stratification of HR-PCI patients, outlines the evidence base underpinning MCS in HR-PCI and discusses a practical, integrated approach for HR-PCI.