Cutting balloon angioplasty might be considered to avoid slippage-induced coronary artery trauma dur- ing PCI for in-stent restenosis or ostial lesions in side branches.529 (Level of Evidence: C) Class III: NO BENEFIT 1. Cutting balloon angioplasty should not be per- formed routinely during PCI.516,529,530 (Level of Evi- dence: A) Although some small, single-center trials have suggested that cutting balloon angioplasty was more efficacious than bal- Levine et al 2011 ACCF/AHA/SCAI PCI Guideline e603 loon angioplasty, it was not found to be safer or more effective in several large trials.516,529,531 When balloon dila- tion is required for in-stent restenosis, however, cutting balloons are less likely to slip and may offer a technical advantage over conventional balloons.529 Scoring balloons have been used by some cardiologists as an alternative to cutting balloons, but no RCTs have been reported.531 5.5.5. Embolic Protection Devices: Recommendation Class I 1. Embolic protection devices (EPDs) should be used during saphenous vein graft (SVG) PCI when tech- nically feasible.532 535 (Level of Evidence: B) The incidence of MACE doubles in SVG PCI compared with native-artery PCI.536 A distal balloon occlusion EPD de- creased the 30-day composite outcome of death, MI, emer- gency CABG, or target-lesion revascularization (9.6% versus 16.5%) in the only RCT.532 Subsequent noninferiority com- parisons have demonstrated similar benefit with proximal occlusion and distal filter EPDs, with benefit limited to reduction in periprocedural MI534,535 (Section 5.10). Distal EPDs do not improve survival or reinfarction rates in patients undergoing native-artery PCI.524,537 5.6. Percutaneous Hemodynamic Support Devices: Recommendation Class IIb 1. Elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reason- able in carefully selected high-risk patients. 