Interventional cardiologists have recently become increasingly entrusted with the treatment of frail patients with complex coronary anatomy. Additionally, calcified lesions (CLs) have become more common due to the continued increase in the older population worldwide, increasing the need for simpler treatment options for such complex lesions. Hence, numerous debulking tools have recently been developed to overcome the difficulties associated with the angioplasty of CLs and to optimize stent positioning and delivery. In addition, bifurcation lesions (BLs) have always been more challenging than other lesions, requiring more specialized tools and complex strategies. Finally, intravascular imaging (IVI) is becoming increasingly important in assessing the complexity of lesions and optimizing procedural approaches. This article provides an overview of how complex procedures should be approached, from the choice of access and catheter to the use of specialized devices developed to assist cardiac catheterization laboratory operators in these complex scenarios.

The treatment of coronary artery disease (CAD) has considerably evolved over the last three decades thanks to innovations in percutaneous and surgical revascularization techniques. The demographic shift towards an aging population with complex coronary anatomy and multiple comorbidities necessitates a personalized approach. A primary challenge for Heart Teams is to integrate new strategies into their decision-making process. Hybrid coronary revascularization (HCR) combines the long-term benefits of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) to treat complex coronary artery disease. Selection of the ideal candidate for HCR requires careful evaluation of anatomic challenges and risk profiles. Although recent evidence demonstrates the safety and efficacy of HCR and makes it a viable alternative to conventional methods, further large-scale randomized controlled trials (RCTs) are needed to establish its role in routine practice. In this manuscript, we have provided an overview of the major advances in both percutaneous and surgical techniques. In addition, we have addressed the innovative implications of robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) and described the surgical procedure and postoperative care in detail. Finally, we have outlined the key principles that guide our clinical practice in selecting the appropriate approach for hybrid coronary revascularization.

Background: a wider left main bifurcation angle (LMBA) has been linked to severe plaque development in the proximal left anterior descending artery (LAD). This study aimed to identify predictors of severe proximal LAD stenosis and major adverse cardiovascular events (MACE) using coronary computed tomography angiography (CCTA). Methods: from an initial cohort of 650 consecutive patients, we analyzed 499 patients who met the inclusion criteria after exclusions. Plaque morphology and characteristics were assessed by CCTA, and MACE occurrences were recorded at follow-up. A predictive score for LAD disease progression (CLAP score) was developed and validated. Results: severe proximal LAD stenosis was detected in 32% (160/499) of patients by CCTA. MACE occurred in 12.5% of patients at follow-up. Significant predictors of MACE were LMBA > 80° (HR: 4.47; 95% CI: 3.80–6.70; p < 0.001), diabetes (HR: 2.94; 95% CI: 1.54–4.63; p = 0.031), chronic kidney disease (HR: 1.71; 95% CI: 1.31–6.72; p = 0.041), high-risk plaques (HR: 2.30; 95% CI: 1.45–3.64; p < 0.01), obstructive CAD (HR: 2.50; 95% CI: 1.50 to 4.10, p = 0.01), and calcium score (CAC) (HR: 1.05; 95% CI: 1.02–1.08, p = 0.004). The CLAP score demonstrated good discriminatory power in both the development (AUC 0.91; 95% CI: 0.86–0.96) and validation cohorts (AUC 0.85; 95% CI: 0.79–0.91); Conclusions: LMBA > 80°, diabetes, chronic kidney disease, obstructive CAD, CAC score >180 and high-risk plaques were significant predictors of MACE in CCTA patients. The CLAP score effectively predicted LAD disease progression, aiding in risk stratification and optimization of intervention strategies for suspected coronary artery disease.