Percutaneous coronary intervention in cardiac allograft vasculopathy: From lesion selection to longitudinal graft management.

Cardiac allograft vasculopathy remains a major cause of late graft dysfunction and mortality after heart transplantation. Percutaneous coronary intervention can treat focal epicardial disease, but its role is complicated by diffuse epicardial involvement, microvascular dysfunction, donor-transmitted or conventional atherosclerosis, alloimmune injury, and limited transplant-specific interventional evidence. This narrative review examines cardiac allograft vasculopathy from the perspective of the interventional cardiologist, focusing on lesion selection, procedural optimization, and longitudinal management after intervention. Longitudinal graft assessment contextualizes whether a stenosis reflects donor-derived disease, acquired atherosclerosis, progressive alloimmune vasculopathy, or overlapping processes, while donor-specific antibodies and rejection history provide complementary information regarding alloimmune risk. Coronary angiography remains central when revascularisation is contemplated, with intravascular imaging defining vessel dimensions, disease distribution, and procedural strategy. Coronary computed tomography angiography can exclude significant epicardial disease in appropriately selected recipients, whereas functional imaging and invasive coronary physiology characterize graft-wide haemodynamic and microvascular disease. However, no single anatomical, physiological, or immunological threshold has been prospectively validated for percutaneous coronary intervention. Drug-eluting stents are generally favored for suitable focal lesions based on lower restenosis rates, although graft-level clinical benefit remains unproven. Post-intervention management should distinguish target-lesion failure from graft-wide disease progression and incorporate continued surveillance and transplant-directed disease modification. By distinguishing guideline-supported and transplant-specific evidence from native coronary extrapolation, this review proposes an evidence-informed interpretive framework in which percutaneous coronary intervention treats a mechanically correctable component of graft vascular disease rather than allograft vasculopathy itself.