Alex Truesdell, MD, provides a high-level overview of contemporary considerations for complex and high-risk PCI in this virtual presentation from the Cardiovascular Research Technologies (CRT) virtual annual symposium in 2021. Dr. Truesdell highlights several key points including the importance of differentiating “complex” from “high-risk” PCI, case planning, ongoing training, vascular access, calcium management, bifurcation techniques, mechanical circulatory support (MCS) options, and the importance of handling complications and holding after action reviews.

“I think it’s important to differentiate between high-risk and complex,” Dr. Truesdell explains. “Sometimes they travel together, sometimes not, and that’s going to influence various techniques you may use and whether you use circulatory support.”

Dr. Truesdell emphasizes that complicated and complex PCI cases require a focus on fundamental skills, the most important of which is planning. He explains that top physicians efficiently get through complex cases by “meticulous planning before.”

With regard to vascular access, Dr. Truesdell explains, “when you’re talking about large bore devices, you really have to make sure that your vascular access is meticulous in planning and in entry and in closure.”

Another topic he touches on is calcium management and the importance of becoming expert in the use of one or more of the available tools, emphasizing, “make sure that you use a device based on the lesion, not just based on your familiarity.” He also explains that bifurcation techniques is “a field unto itself” and that there are many resources available to learn more about it.

Dr. Truesdell briefly reviews an MCS decision algorithm, with questions pertaining to anatomy, patient comorbidities, and hemodynamics, to review when deciding whether to use MCS. He mentions that there are many MCS devices available, noting, “probably for most operators, the Impella® is the simplest and easiest and most universally usable platform at present.”

Dr. Truesdell briefly reviews a couple of cases that highlight the skills and considerations he’s mentioned. “Not only is planning, planning, planning important,” he states, “but knowing what to do with complications and what happens when the plan changes.” He also emphasizes the importance of after action reviews. “After a successful case or unsuccessful case, huddle with your team and talk about what went well, what didn’t, and just get better as you go along.”