Despite guidelines to the contrary, limited numbers of elective percutaneous coronary intervention (PCI) procedures without on-site surgical backup are being performed, particularly in Europe and Canada. In the United States, many hospitals are considering establishing on-site surgical programs, in part to facilitate PCI. At a hospital with only off-site surgical backup, 562 elective PCI procedures were performed on 489 consecutive patients. Of these, 551 (98.0%) were successfully completed without major in-hospital complications; 5 patients (1.0%) had in-hospital complications, and 4 (0.8%) were urgently transferred. It is concluded that elective PCI with off-site surgical backup is feasible and safe for selected patients under specific conditions.