Risk Stratification and Peri-procedural Optimization in Complex Percutaneous Coronary Interventions: Evidence-based Insights for Improved Patient Outcomes

Abstract

Complex percutaneous coronary intervention (PCI) is increasingly performed in patients with advanced coronary artery disease, multiple comorbidities, and high procedural risk, making accurate risk stratification and peri-procedural optimization essential to improving outcomes. Contemporary risk assessment integrates anatomical complexity scores such as the SYNTAX and residual SYNTAX scores with clinical models including GRACE, ACEF, and registry-based prediction tools to guide procedural planning and clinical decision-making. Beyond risk prediction, peri-procedural optimization strategies have evolved to include physiological lesion assessment using fractional flow reserve and instantaneous wave-free ratio, intravascular imaging guidance with intravascular ultrasound and optical coherence tomography, and refined antithrombotic and vascular access strategies to minimize ischemic and bleeding complications. Hemodynamic support devices such as intra-aortic balloon pump, Impella, and extracorporeal membrane oxygenation have expanded the therapeutic window for high-risk PCI in patients with impaired ventricular function or cardiogenic shock. Additionally, advances in patient selection, multidisciplinary heart team approaches, and tailored peri-procedural pharmacotherapy have contributed to improved procedural safety and long-term outcomes. Despite these advancements, challenges remain in integrating complex risk models into routine practice and defining optimal strategies for specific high-risk subgroups. This review synthesizes current evidence on risk stratification frameworks and peri-procedural optimization techniques in complex PCI, highlighting emerging tools and future directions to enhance personalized interventional cardiology care and improve patient-centered outcomes.