Clinical Research in Cardiology

, Volume 107, Supplement 2, pp 64–73 | Cite as

Complex PCI procedures: challenges for the interventional cardiologist

  • Nikos WernerEmail author
  • Georg Nickenig
  • Jan-Malte Sinning


In recent years, the percentage of patients with multivessel disease and multiple complex stenoses have significantly increased. One factor contributing to this increase is the proportion of elderly and very elderly patients who have been turned down by the Heart Team for surgical revascularization (Landes et al. in Catheter Cardiovasc Interv,, 2017; Waldo et al. in Circulation 130:2295–2301,, 2014). In addition, the marked increase in patients with significant comorbidities further contributes to the increase in patients referred to the interventional cardiologist for stenting procedures. Mostly, the complexity of these patients is characterized not only by their comorbidities but also by multivessel disease, bifurcation disease, left main disease, or stenoses of calcified or tortuous vessels, degenerated saphenous vein graft lesions, and thrombotic lesions (Kirtane et al. in Circulation 134:422–431, 2016; Gennaro Giustino et al. in JACC 86:1851–1864, 2016) These specific lesion types are typically associated with lower rates of procedural success and higher rates of recurrence or major adverse cardiac events (Kirtane et al. 2016) Coming along with this problem, virtually no study exists evaluating revascularization strategies, i.e. percutaneous coronary intervention (PCI), coronary artery bypass graft surgery, or medical therapy alone in complex patients with complex coronary anatomy. Therefore, we are confronted with an increasing patient population that is understudied and potentially underserved. In the absence of robust, accurate, objective, and consistent evidence which could help us in decision-making (e.g. best revascularization strategy, complication prevention, post-interventional medical therapy), we have to stick to personal experience and patients’ preferences. In this article, we provide an overview about common definition of complex PCI, general strategies to help decision-making in these patients, and give an overview about post-interventional medical treatment.


PCI procedures 


  1. 1.
    Landes U, Bental T, Levi A, Assali A, Vaknin-Assa H, Lev EI, Rechavia E, Greenberg G, Orvin K, Kornowski R (2017) Temporal trends in percutaneous coronary interventions thru the drug eluting stent era: insights from 18,641 procedures performed over 12-year period. Catheter Cardiovasc Interv. (Epub ahead of print)
  2. 2.
    Waldo SW, Secemsky EA, O’Brien C, Kennedy KF, Pomerantsev E, Sundt TM III, McNulty EJ, Scirica BM, Yeh RW (2014) Surgical ineligibility and mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention. Circulation 130:2295–2301. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, Mack MJ, Holmes DR Jr, Morel MA, Van Dyck N, Houle VM, Dawkins KD, Serruys PW (2013) Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 381:629–638. CrossRefPubMedGoogle Scholar
  4. 4.
    Escaned J, Collet C, Ryan N, De Maria GL, Walsh S, Sabate M, Davies J, Lesiak M, Moreno R, Cruz-Gonzalez I, Hoole SP, Ej West N, Piek JJ, Zaman A, Fath-Ordoubadi F, Stables RH, Appleby C, van Mieghem N, van Geuns RJ, Uren N, Zueco J, Buszman P, Iñiguez A, Goicolea J, Hildick-Smith D, Ochala A, Dudek D, Hanratty C, Cavalcante R, Kappetein AP, Taggart DP, van Es GA, Morel MA, de Vries T, Onuma Y, Farooq V, Serruys PW, Banning AP (2017) Clinical outcomes of state-of-the-art percutaneous coronary revascularization in patientswith de novo three vessel disease: 1-year results of the SYNTAX II study. Eur Heart J 7(42):3124–3134. 38) .CrossRefGoogle Scholar
  5. 5.
    Kirtane AJ, Doshi D, Leon MB, Lasala JM, Ohman EM, O’Neill WW, Shroff A, Cohen MG, Palacios IF, Beohar N, Uriel N, Kapur NK, Karmpaliotis D, Lombardi W, Dangas GD, Parikh MA, Stone GW, Moses JW (2016) Treatment of higher-risk patients with an indication for revascularization: evolution within the field of contemporary percutaneous coronary intervention. Circulation 134:422–431. CrossRefPubMedGoogle Scholar
  6. 6.
    Dangas GD, Kini AS, Sharma SK, Henriques JP, Claessen BE, Dixon SR, Massaro JM, Palacios I, Popma JJ, Ohman M, Stone GW, O’Neill WW (2014) Impact of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump on prognostically important clinical outcomes in patients undergoing high-risk percutaneous coronary intervention (from the PROTECT II randomized trial). Am J Cardiol 113:222–228. CrossRefPubMedGoogle Scholar
  7. 7.
    Rihal CS, Naidu SS, Givertz MM, Szeto WY, Burke JA, Kapur NK, Kern M, Garratt KN, Goldstein JA, Dimas V, Tu T, Society for Cardiovascular Angiography and Interventions (SCAI), Heart Failure Society of America (HFSA), Society of Thoracic Surgeons (STS), American Heart Association (AHA), and American College of Cardiology (ACC) (2015) 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care: endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiología Intervencionista; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d’intervention. J Am Coll Cardiol 65:2140–2141. CrossRefPubMedGoogle Scholar
  8. 8.
    Sandhu A, McCoy LA, Negi SI, Hameed I, Atri P, Al’Aref SJ, Curtis J, McNulty E, Anderson HV, Shroff A, Menegus M, Swaminathan RV, Gurm H, Messenger J, Wang T, Bradley SM (2015) Use of mechanical circulatory support in patients undergoing percutaneous coronary intervention: insights from the National Cardiovascular Data Registry. Circulation 132:1243–1251. CrossRefPubMedGoogle Scholar
  9. 9.
    Baumann S, Werner N, Ibrahim K, Westenfeld R, Al-Rashid F, Sinning JM, Westermann D, Schäfer A, Karatolios K, Bauer T, Becher T, Akin I (2018) Indication and short-term clinical outcomes of high-risk percutaneous coronary intervention with microaxial Impella® pump: results from the German Impella® registry. Clin Res Cardiol. PubMedCrossRefGoogle Scholar
  10. 10.
    Werner N, Akin I, Al-Rashid F, Bauer T, Ibrahim K, Karatolios K, Mellert F, Schäfer A, Sinning J-M, Werner GS, Westenfeld R, Westermann D, Elsässer A (2017) Expertenkonsensus zum praktischen Einsatz von Herzkreislaufunterstützungssystemen bei Hochrisiko-Koronarinterventionen. Kardiologe 11:460–472. CrossRefGoogle Scholar
  11. 11.
    Tonino PA, Fearon WF, De Bruyne B, Oldroyd KG, Leesar MA, Ver Lee PN, Maccarthy PA, Van’t Veer M, Pijls NH (2010) Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol 55(25):2816–21. CrossRefPubMedGoogle Scholar
  12. 12.
    Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Ståhle E, Feldman TE, van den Brand M, Bass EJ, Van Dyck N, Leadley K, Dawkins KD, Mohr FW, SYNTAX Investigators (2009) Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. SYNTAX study. NEJM. CrossRefPubMedGoogle Scholar
  13. 13.
    Peace A, Barbato E (2011) FFR for decision making in complex PCI. Cardiac Interv Today 2011:53–56Google Scholar
  14. 14.
    Pijls NH, van Son JA, Kirkeeide RL, De Bruyne B, Gould KL (1993) Experimental basis of determining maximum coronary, myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after percutaneous transluminal coronary angioplasty. Circulation 87:1354–1367CrossRefPubMedGoogle Scholar
  15. 15.
    De Bruyne B, Sarma J (2008) Fractional flow reserve: a review: invasive imaging. Heart 94:949–959. CrossRefPubMedGoogle Scholar
  16. 16.
    Hildick-Smith D, de Belder AJ, Cooter N, Curzen NP, Clayton TC, Oldroyd KG, Bennett L, Holmberg S, Cotton JM, Glennon PE, Thomas MR, Maccarthy PA, Baumbach A, Mulvihill NT, Henderson RA, Redwood SR, Starkey IR, Stables RH (2010) Randomized trial of simple versus complex drug-eluting stenting for bifurcation lesions: the British Bifurcation Coronary Study: old, new, and evolving strategies. Circulation 121:1235–1243. CrossRefPubMedGoogle Scholar
  17. 17.
    Behan MW, Holm NR, de Belder AJ, Cockburn J, Erglis A, Curzen NP, Niemelä M, Oldroyd KG, Kervinen K, Kumsars I, Gunnes P, Stables RH, Maeng M, Ravkilde J, Jensen JS, Christiansen EH, Cooter N, Steigen TK, Vikman S, Thuesen L, Lassen JF, Hildick-Smith D (2016) Coronary bifurcation lesions treated with simple or complex stenting: 5-year survival from patient-level pooled analysis of the Nordic Bifurcation Study and the British Bifurcation Coronary Study. Eur Heart 37(24):1923–8. CrossRefGoogle Scholar
  18. 18.
    Koo BK, Waseda K, Kang HJ, Kim HS, Nam CW, Hur SH, Kim JS, Choi D, Jang Y, Hahn JY, Gwon HC, Yoon MH, Tahk SJ, Chung WY, Cho YS, Choi DJ, Hasegawa T, Kataoka T, Oh SJ, Honda Y, Fitzgerald PJ, Fearon WF (2010) Anatomic and functional evaluation of bifurcation lesions undergoing percutaneous coronary intervention. Circ Cardiovasc Interv 3:113–119. CrossRefPubMedGoogle Scholar
  19. 19.
    Hong SJ, Kim BK, Shin DH, Nam CM, Kim JS, Ko YG, Choi D, Kang TS, Kang WC, Her AY, Kim YH, Hur SH, Hong BK, Kwon H, Jang Y, Hong MK, IVUS-XPL Investigators (2015) Effect of intravascular ultrasound-guided vs angiography-guided everolimus-eluting stent implantation: the IVUS-XPL randomized clinical trial. JAMA 314:2155–2163. CrossRefPubMedGoogle Scholar
  20. 20.
    Andell P, Karlsson S, Mohammad MA, Götberg M, James S, Jensen J, Fröbert O, Angerås O, Nilsson J, Omerovic E, Lagerqvist B, Persson J, Koul S, Erlinge D (2017) Intravascular ultrasound guidance is associated with better outcome in patients undergoing unprotected left main coronary artery stenting compared with angiography guidance alone. Circ Cardiovasc Interv 10:e004813. CrossRefPubMedGoogle Scholar
  21. 21.
    Stone GW, Sabik JF, Serruys PW, Simonton CA, Généreux P, Puskas J, Kandzari DE, Morice MC, Lembo N, Brown WM III, Taggart DP, Banning A, Merkely B, Horkay F, Boonstra PW, van Boven AJ, Ungi I, Bogáts G, Mansour S, Noiseux N, Sabaté M, Pomar J, Hickey M, Gershlick A, Buszman P, Bochenek A, Schampaert E, Pagé P, Dressler O, Kosmidou I, Mehran R, Pocock SJ, Kappetein AP, EXCEL Trial Investigators (2016) Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med 375:2223–2235. CrossRefPubMedGoogle Scholar
  22. 22.
    Mäkikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, Trovik T, Eskola M, Romppanen H, Kellerth T, Ravkilde J, Jensen LO, Kalinauskas G, Linder RB, Pentikainen M, Hervold A, Banning A, Zaman A, Cotton J, Eriksen E, Margus S, Sørensen HT, Nielsen PH, Niemelä M, Kervinen K, Lassen JF, Maeng M, Oldroyd K, Berg G, Walsh SJ, Hanratty CG, Kumsars I, Stradins P, Steigen TK, Fröbert O, Graham AN, Endresen PC, Corbascio M, Kajander O, Trivedi U, Hartikainen J, Anttila V, Hildick-Smith D, Thuesen L, Christiansen EH, NOBLE Study Investigators (2016) Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet 388:2743–2752. CrossRefPubMedGoogle Scholar
  23. 23.
    Park SJ, Ahn JM, Kang SJ, Yoon SH, Koo BK, Lee JY, Kim WJ, Park DW, Lee SW, Kim YH, Lee CW, Park SW (2014) Intravascular ultrasound-derived minimal lumen area criteria for functionally significant left main coronary artery stenosis. JACC Cardiovasc Interv 7(8):868–874. CrossRefPubMedGoogle Scholar
  24. 24.
    Waksman R, Legutko J, Singh J, Orlando Q, Marso S, Schloss T, Tugaoen J, DeVries J, Palmer N, Haude M, Swymelar S, Torguson R (2013) FIRST: fractional flow reserve and intravascular ultrasound relationship study. J Am Coll Cardiol 61:917–923. CrossRefPubMedGoogle Scholar
  25. 25.
    Fujii K, Carlier SG, Mintz GS, Yang YM, Moussa I, Weisz G, Dangas G, Mehran R, Lansky AJ, Kreps EM, Collins M, Stone GW, Moses JW, Leon MB (2005) Stent underexpansion and residual reference segment stenosis are related to stent thrombosis after sirolimus-eluting stent implantation: an intravascular ultrasound study. J Am Coll Cardiol 45:995–998. CrossRefPubMedGoogle Scholar
  26. 26.
    Witzenbichler B, Maehara A, Weisz G, Neumann FJ, Rinaldi MJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Brodie BR, Stuckey TD, Mazzaferri EL Jr, Xu K, Parise H, Mehran R, Mintz GS, Stone GW (2014) Relationship between intravascular ultrasound guidance and clinical outcomes after drug-eluting stents: the assessment of dual antiplatelet therapy with drug-eluting stents (ADAPT-DES) study. Circulation 129:463–470. CrossRefPubMedGoogle Scholar
  27. 27.
    Regar E, Prati F. Optical coherence tomography. The PCR-EAPCI textbook, vol I, Diagnosis. Part II, Chap 12. Online edition:
  28. 28.
    Ron Waksman F, Prati GS, Mintz H, Kitabata F, Prati M, Albertucci GS, Mintz, Kitabata H, Albertucci M (2013) Intravascular ultrasound versus optical coherence tomography guidance. JACC 62(17):S32–S40. CrossRefPubMedGoogle Scholar
  29. 29.
    Head SJ, Milojevic M, Daemen J, Ahn JM, Boersma E, Christiansen EH, Domanski MJ, Farkouh ME, Flather M, Fuster V, Hlatky MA, Holm NR, Hueb WA, Kamalesh M, Kim YH, Mäkikallio T, Mohr FW, Papageorgiou G, Park SJ, Rodriguez AE, Sabik JF III, Stables RH, Stone GW, Serruys PW, Kappetein AP (2018) Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet 391(10124):939–948. (Epub 2018 Feb 23) CrossRefPubMedGoogle Scholar
  30. 30.
    Farooq V, Serruys PW, Garcia-Garcia HM, Zhang Y, Bourantas CV, Holmes DR, Mack M, Feldman T, Morice MC, Ståhle E, James S, Colombo A, Diletti R, Papafaklis MI, de Vries T, Morel MA, van Es GA, Mohr FW, Dawkins KD, Kappetein AP, Sianos G, Boersma E (2013) The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial. J Am Coll Cardiol 61:282–294. CrossRefPubMedGoogle Scholar
  31. 31.
    Aggarwal V, Rajpathak S, Singh M, Romick B, Srinivas VS (2012) Clinical outcomes based on completeness of revascularisation in patients undergoing percutaneous coronary intervention: a meta-analysis of multivessel coronary artery disease studies. EuroIntervention 7:1095–1102. CrossRefPubMedGoogle Scholar
  32. 32.
    Feldman DN, Kim L, Rene AG, Minutello RM, Bergman G, Wong SC (2011) Prognostic value of cardiac troponin-I or troponin-T elevation following nonemergent percutaneous coronary intervention: a meta-analysis. Catheter Cardiovasc Interv 77(7):1020–30. (Epub 2011 May 13) CrossRefPubMedGoogle Scholar
  33. 33.
    Liu Y, Chen JY, Tan N, Zhou YL, Yu DQ, Chen ZJ, He YT, Liu YH, Luo JF, Huang WH, Li G, He PC, Yang JQ, Xie NJ, Liu XQ, Yang DH, Huang SJ, Ye P, Li HL, Ran P, Duan CY, Chen PY (2015) Safe limits of contrast vary with hydration volume for prevention of contrast-induced nephropathy after coronary angiography among patients with a relatively low risk of contrast-induced nephropathy. Circ Cardiovasc Interv 8(6):e001859. CrossRefPubMedGoogle Scholar
  34. 34.
    Chalikias G, Drosos I, Tziakas DN (2016) Contrast-induced acute kidney injury: an update. Cardiovasc Drugs Ther 30(2):215–228. CrossRefPubMedGoogle Scholar
  35. 35.
    Giustino G, Chieffo A, Palmerini T, Valgimigli M, Feres F, Abizaid A, Costa RA, Hong M-K, Kim B-K, Jang Y, Kim H-S, Park KW, Gilard M, Morice M-C, Sawaya F, Sardella G, Genereux P, Redfors B, Leon MB, Bhatt DL, Stone GW, Colombo A (2016) Efficacy and safety of dual antiplatelet therapy after complex PCI. JACC 17:1851–1864. CrossRefGoogle Scholar
  36. 36.
    Yeh RW, Kereiakes DJ, Steg PG, Cutlip DE, Croce KJ, Massaro JM, Mauri L, DAPT Study Investigators (2017) Lesion complexity and outcomes of extended dual antiplatelet therapy after percutaneous coronary intervention. J Am Coll Cardiol 70(18):2213–2223. CrossRefPubMedGoogle Scholar
  37. 37.
    Chandrasekhar J, Baber U, Sartori S, Aquino M, Kini AS, Rao S, Weintraub W, Henry TD, Farhan S, Vogel B, Sorrentino S, Ge Z, Kapadia S, Muhlestein JB, Weiss S, Strauss C, Toma C, DeFranco A, Effron MB, Keller S, Baker BA, Pocock S, Dangas G, Mehran R (2018) Associations between complex PCI and prasugrel or clopidogrel use in patients with acute coronary syndrome who undergo PCI: from the PROMETHEUS study. Can J Cardiol 34(3):319–329. CrossRefPubMedGoogle Scholar
  38. 38.
    Members TF, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabaté M, Senior R, Taggart DP, van der Wall EE, Vrints CJ, ESC Committee for Practice Guidelines, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Document Reviewers, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Rydén L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL (2013) 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 34:2949–3003. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Nikos Werner
    • 1
    Email author
  • Georg Nickenig
    • 1
  • Jan-Malte Sinning
    • 1
  1. 1.Medizinische Klinik und Poliklinik II, Herzzentrum BonnUniversitätsklinikum BonnBonnGermany

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