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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e57 CLINICAL STATEMENTS AND GUIDELINES of ISR should be individualized. Importantly, intensive medical therapy is also vital in these patients. Recommendation-Specific Supportive Text 1. In patients with ISR, studies have shown that treatment with a DES resulted in lower rates of targetvessel restenosis in follow-up than those seen with BMS or balloon angioplasty.3,4,17 Network metaanalyses comparing various treatment options (DES, BMS, vascular brachytherapy, drug-coated balloons, conventional balloons, or rotational atherectomy) have shown that PCI with a DES was associated with the lowest rates of restenosis and target-vessel revascularization. Of the different DES stent types, everolimus-eluting stents appeared to have the best efficacy.1,2 In these studies, there were no significant differences in other clinical outcomes, including death or MI, among the therapies examined. 2. In patients with recurrent episodes of restenosis despite repeat PCI with DES, or in patients who have diffuse ISR in large vessels or a complex presentation such as CTO with multivessel disease, CABG maybe the preferred approach if the anatomy is suitable. 3. In patients who already have multiple stent layers or have recurrent ISR with an artery that is unfavorable to receive another DES, who are not good candidates for bypass surgery, vascular brachytherapy provides an additional tool to aid revascularization.5 Vascular brachytherapy circumvents the need to implant another stent, and in these challenging situations it remains a reasonable option. 10.9 Hemodynamic Support for Complex PCI Recommendation for Hemodynamic Support in Complex PCI Referenced studies that support the recommendation are summarized in Online Data Supplement 31. COR LOE Recommendation 2b B-R 1. In selected high-risk patients, elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable to prevent hemodynamic compromise during PCI.1,2 Synopsis Patients undergoing complex PCI are at risk of hypotension, decompensated heart failure, shock, or arrhythmias that may lead to rapid hemodynamic deterioration or death. Intra-aortic balloon pump counterpulsation provides minimal hemodynamic support for PCI but improves coronary and cerebral perfusion. Its use is limited in patients with severe peripheral artery or aortic disease. Its advantages are ease of use and smaller catheter diameter, leading to lower rates of vascular access site complications. The Impella percutaneous left ventricular–assist devices (Abiomed, Danvers, MA) provide greater left ventricular support. The use of the Impella support devices is limited in patients with left ventricular thrombus, aortic stenosis, peripheral artery disease, or aortic disease. Extracorporeal membrane oxygenation and the TandemHeart (CardiacAssist, Inc, Pittsburgh, PA) devices are rarely used to support complex PCI. New hemodynamic support devices are undergoing evaluation in clinical trials. Recommendation-Specific Supporting Text 1. The routine use of hemodynamic support devices for complex PCI has not been shown to reduce cardiovascular events.1,2 In the BCIS-1 (Balloon Pump–Assisted Coronary Intervention) study, there was no difference in the primary composite outcome (death, MI, cerebrovascular event, or repeat revascularization) with intra-aortic balloon counterpulsation.1 Major procedural complications (mostly hypotension) were lower with intra-aortic balloon counterpulsation. The PROTECT II (Prospective, Multi-center, Randomized Controlled Trial of the Impella Recover LP 2.5 System Versus Intra Aortic Balloon Pump [IABP] in Patients Undergoing Non Emergent High Risk PCI II) trial, comparing the Impella System with intra-aortic balloon counterpulsation for high-risk PCI, was halted for futility after an interim analysis showed no benefit in the primary endpoint of MACE.2 Compared with balloon counterpulsation, Impella provided better hemodynamic support. Observational studies have further challenged the efficacy, safety, and cost of hemodynamic support devices.3,4 Despite these findings, these devices can provide hemodynamic support in select patients during complex PCI with multivessel disease, left main disease, or disease of the last patent conduit and severe left ventricular dysfunction or cardiogenic shock.5-9 11 PHARMACOTHERAPY IN PATIENTS UNDERGOING PCI 11.1 Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI Recommendations for Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI Referenced studies that support the recommendations are summarized in Online Data Supplement 32. COR LOE Recommendations 1 B-R 1. In patients undergoing PCI, a loading dose of aspirin, followed by daily dosing, is recommended to reduce ischemic events.1-4* *Contraindications to ticagrelor: previous intracranial hemorrhage or ongoing bleeding. Contraindications to prasugrel: previous intracranial hemorrhage, previous ischemic stroke or transient ischemic attack, or ongoing bleeding. Prasugrel should be used with caution at a lower dose in patients ≥75 years of age or with a body weight <60 kg. Downloaded from http://ahajournals.org by on October 7, 2026