Patient selection for complex, high-risk indicated percutaneous coronary intervention procedures: an overview

Percutaneous coronary intervention (PCI) has evolved substantially over recent decades, enabling treatment of increasingly complex coronary anatomy through major technological advances, including enhanced stent platforms, intracoronary imaging, plaque modification devices, and mechanical circulatory support (MCS). Despite these developments, coronary artery bypass grafting often remains the guideline-preferred strategy for patients with complex and prognostically significant coronary artery disease. However, patients with complex and advanced coronary artery disease are often older and burdened by greater comorbidity than those enrolled in randomized clinical trials, rendering many patients poor surgical candidates, and prompting preference for less invasive therapies to preserve quality of life. This shift has driven the emergence of complex, high-risk indicated PCI (CHIP) and protected PCI as alternative treatment strategies. CHIP encompasses both anatomical complexity and heightened procedural risk related to haemodynamic compromise and patient comorbidities. As randomized trials capture only a small subset of real-world patients and are often subject to selection bias, current practice relies heavily on observational data-derived largely from registries, expert consensus, and institutional experience-to guide selection of patients most likely to benefit from MCS support. This review synthesizes available contemporary evidence and consensus frameworks to delineate the multifactorial nature of CHIP risk, organizing key determinants into four categories: complex coronary anatomy, impaired haemodynamics, cardiac comorbidities, and non-cardiac comorbidities. Understanding how these factors influence procedural risk, patient selection, and therapeutic benefit is essential to decision-making and optimization of outcomes in this vulnerable population.