Vascular access options for complex high-risk indicated percutaneous coronary interventions: contemporary strategies,...

Vascular access is an important component of CHIP planning that influences procedural feasibility, safety, and completeness. It affects bleeding and vascular complications, guide-catheter support, compatibility with intravascular imaging and calcium-modification devices, chronic total occlusion techniques, closure and bailout options, and mechanical circulatory support (MCS) planning. Contemporary CHIP populations are increasingly older or frail and more often have chronic kidney disease, peripheral artery disease, reduced left ventricular ejection fraction, prior bypass surgery, calcification, or CTO; access choice should extend beyond radial vs. femoral.

This review appraises proximal and distal radial, femoral, ulnar, and brachial access; sheathless, slender, and RailTracking strategies; large-bore femoral workflows; and access planning when MCS is considered. We discuss preprocedural arterial assessment, ultrasound and micropuncture, prior access footprint, closure feasibility, hostile femoral anatomy, alternative access, and complication prevention and rescue. The available literature supports a non-dogmatic approach in which access architecture is matched to patient vulnerability, arterial anatomy, lesion complexity, guide and device requirements, support needs, haemostasis feasibility, and bailout planning. Recent randomised evidence further reinforces selective rather than routine prophylactic MCS in nonemergent high-risk PCI.

Forearm access should remain central whenever it permits procedural success without compromising device delivery, imaging, guide support, or bailout flexibility. Femoral access remains indispensable when large-bore support, maximal guide stability, complex device delivery, or rapid escalation are anticipated. Within a comprehensive CHIP plan, the preferred access architecture is the smallest one that enables the intended revascularisation, safe haemostasis, and timely rescue.