Innovations in Interventional Cardiology: A Critical Review of Strategies for Complex and High-Risk Percutaneous Coronary Intervention

The field of interventional cardiology has rapidly progressed, given recent advances in the management of complex, high-risk indicated percutaneous coronary intervention. These procedures are becoming increasingly necessary due to the aging population and increasing comorbidity burden. Expanded procedural capabilities have been made possible through innovations in mechanical circulatory support (MCS) devices, drug-coated balloons, and intravascular lithotripsy, which have enhanced procedural safety and enabled revascularization in patients previously considered inoperable. This critical review synthesizes emerging evidence from randomized trials, observational studies, and current guidelines to examine the role of support strategies in complex, high-risk indicated percutaneous coronary intervention. We explore clinical definitions, risk stratification tools, comparative efficacy of MCS devices, drug-coated balloons, and intravascular lithotripsy, as well as ongoing trials and future technologies like PulseCath and TandemHeart. These studies emphasize the importance of personalized, multidisciplinary strategies that integrate MCS, advanced lesion preparation, and imaging-guided decision-making. As the field evolves toward safer, more individualized care, further research is necessary to determine optimal device selection and long-term outcomes.