SCAI Expert Consensus Statement on Percutaneous Coronary Intervention Without On-Site Surgical Backup

•Elective PCI in settings without SOS has increased in volume and complexity (extending beyond the simple lesion recommendations in the 2014 document). In addition, PCI is now being performed outside the hospital setting, in OBLs and ASCs.•Several new studies in the United States and abroad have demonstrated that PCIs performed at non-SOS centers have very low rates of complications and similar outcomes to PCIs performed at surgical centers.•Despite increases in age, comorbidities, and lesion complexity, the rate of periprocedural complications has remained constant, or declined, with rates of emergency surgery as low as 0.1% in many series.•Complex PCI, including unprotected left main, is being performed at some non-SOS centers, with no increase in MACE or emergency CABG surgery compared with PCI at surgical centers. There have been no comparative studies in other complex PCI subgroups, such as CTO and atherectomy, but observational studies demonstrate reasonable outcomes and suggest feasibility with experienced interventional cardiologists.•The authors propose a new PCI treatment algorithm (Figure 1) that expands the type of cases that can be performed without SOS compared with the 2014 document, with consideration of patients’ clinical and lesion risk, operator experience (both recent and accumulated), and the experience and rescue capabilities of the site.•In the United States, there are considerable financial savings (to insurers and Medicare) for PCI to be performed at ASCs and OBLs, so out-migration of procedures from hospitals should be anticipated.