Coronary Complications During PCI: Contemporary Management and Recent Advances

Purpose of Review Coronary complications during percutaneous coronary intervention (PCI) are uncommon but may lead to abrupt hemodynamic deterioration, myocardial infarction, cardiac tamponade, emergency surgery, other adverse clinical outcomes, or death. As contemporary PCI is increasingly performed in patients with complex coronary anatomy and greater clinical risk, prompt recognition and familiarity with complication-management strategies remain essential. This focused review summarizes contemporary management of coronary perforation, acute vessel closure, and equipment loss or entrapment, with emphasis on recent advances. Recent Findings Recent developments in coronary perforation management include flow-preserving perfusion balloons, improved deliverability and optimization of covered stents, covered-stent fenestration for bifurcation perforations, contemporary embolization strategies, and emerging data regarding anticoagulation reversal. For acute vessel closure, intravascular imaging and chronic total occlusion-derived dissection and re-entry techniques can facilitate restoration of true-lumen flow when conventional rewiring fails, while intracoronary epinephrine and other adjunctive therapies have expanded treatment options for refractory no-reflow. Recent advances in equipment loss and entrapment include novel guidewire-retrieval techniques and percutaneous bailout strategies for entrapped atherectomy devices. Summary Most coronary complications can be managed percutaneously when recognized early and treated with a stepwise approach. A systematic approach incorporating pre-procedural preparation, intraprocedural vigilance and escalation, and structured post-procedural follow-up may further improve outcomes.