Challenging situations in primary percutaneous coronary intervention: clinical scenarios and main approaches

Primary percutaneous coronary intervention (PCI) is one of the most effective treatment modalities for acute life-threatening diseases. Although successful PCI provides a direct positive effect on patient survival, failure may be associated with the disappearance of this benefit and, beyond that, worsening of the prognosis. Disparities in the coronary anatomy, the pathologic nature of the culprit lesion, and the underlying mechanisms of acute coronary syndrome can complicate PCI. An invasive cardiologist must be aware of these challenging situations and how best to manage them. This review aims to summarize troublesome scenarios such as no-reflow, large thrombotic lesions, ectasia-associated myocardial infarction, and spontaneous coronary artery dissection in primary PCI and to provide practical information on how to manage these situations.