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Interventional cardiologists are increasingly being called upon to perform complex revascularization in patients who are deemed not to be candidates for surgical revascularization and, until recently, many of these patients would have only been offered medical management. Further, changing demographics have resulted in an increasingly elderly and frail population with diabetes and chronic kidney disease being referred for revascularization. Owing to the increasing prevalence of coronary artery calcification and the importance of achieving complete revascularization, advanced tools and techniques are required to safely revascularize this patient population. Coronary artery calcification is a marker for increased periprocedural complications and worse long-term outcomes in percutaneous intervention. Its presence may mandate advanced revascularization strategies to facilitate safe revascularization. Several studies have highlighted the importance of intracoronary imaging and there have been iterative changes and new devices that have been developed that can facilitate revascularization in the setting of significant coronary artery calcification. Successful coronary revascularization is increasingly dependent on the rational use of intraavascular imaging, specialized balloons and atherectomy to overcome complex coronary artery disease and calcification. A rational strategy for the safe use of advanced techniques and tools is presented here.

With the recent increase in complex coronary interventions including percutaneous coronary intervention (PCI) for chronic total occlusions and complex higher risk (and indicated) patients, the spectrum of potential periprocedural complications and their prompt management has become even more relevant. Vascular access-related problems remain the most prevalent of all PCI complications and with randomized controlled trial data from over 20,000 patients supporting the superiority of radial over femoral access in reducing bleeding and vascular complications, a default radial strategy should be promoted. The European Society of Cardiology guidelines have acknowledged this by giving a class 1 (level of evidence: A) recommendation for a radial approach for PCI. The US society guidelines, however, have thus far lagged behind. Each individual patient undergoing a PCI should be risk-stratified objectively using available risk prediction models based on patient comorbidities and anatomical and procedural complexities. Customized informed consent should therefore be provided to all patients and should include the potential risks from radiation injury. Here, we review the current data related to common periprocedural complications related to PCI.

The use of intracoronary imaging modalities has seen a significant increase over the past decade, as both imaging quality and delivery systems have improved. Generally accepted best practice indications for using intracoronary imaging include assessment of lesion characteristics prior to stent placement, optimization of stent placement with respect to appropriate sizing, adequate apposition, and expansion and exclusion of edge dissection. Intracoronary imaging plays a particular role in the setting of contemporary left main and bifurcation stenting. Stent interrogation using intracoronary imaging to exclude mechanical causes in the management of in-stent thrombosis has also become conventional. Current clinical guideline recommendations, however, have lagged behind contemporary practice patterns and the use of intravascular ultrasound only carries a class IIa recommendation in the appropriate clinical setting. We discuss the currently available intracoronary imaging modalities and their applications, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), and review the data supporting their use.