Objectives: Numerous clinical trials have established the feasibility of multi-vessel PCI in selected patients (pts). There is limited data, especially from the Middle East, on pts in which surgery was deemed too high risk and multi-vessel PCI was performed. We hypothesize that multi-vessel PCI can be performed in such pts with acceptable one year major adverse cerebral and cardiac event (MACCE) rates. Methods: Chart review was performed from October 2005 till December 2007. Pts that were considered poor surgical candidates and underwent multi-vessel PCI were included in this retrospective cohort analysis. Data was collected on demographic variables, clinical features, Logistic EuroSCORE and Syntax score. These pts were followed for one year and data on MACCE was also recorded. Statistical analysis was performed on SPSS 16.0 software. Results: Sixty seven pts were treated with multi-vessel PCI. Mean age was 64 years with males comprising 70% of the cohort. All pts had recent acute coronary syndrome. Previous history of DM, HTN, tobacco abuse and dyslipidemia was present in 76%, 76%, 28% and 61% of pts respectively. Seven patients were clinically in acute cardiogenic shock. Triple vessel disease was found in 90% of the pts. CABG was refused due to poor coronary targets secondary to diffuse CAD and significand co-morbidities in 36 (54%) and 21 (31%) pts respectively. Mean logistics EuroSCORE and Syntax score was 21.6 and 31.1 respectively. PCI was successfully performed in all pts. At one year follow-up there was one reported death (1.5%) and four non-fatal MI (5.9%). Overall one year MACCE rate was 22.4% primarily driven by target lesion revascularization in 10 pts (14.9%). Conclusions: This pilot study from the Middle East of Saudi patients who are not good candidates for surgical revascularization, demonstrates that multi-vessel PCI of patients with significant co-morbidities and high syntax scores can be a reasonable alternative to CABG with acceptable one year MACCE rates.