The goal of a recent study published in Atherosclerosis was to provide a complete assessment on the associations between single or combined cardiovascular (CV) ultrasound indices, and the complexity of coronary artery disease (CAD) in high and very-high risk patients. This study enrolled 215 patients scheduled for elective coronary angiography. The results showed that patients (79% with a very high CV risk) had central obesity (77%), and arterial hypertension (81%). Meanwhile, one-third (37%) had diabetes and most of the individuals (74%) were current or previous smokers. In the study group, male sex, higher number of CV risk factors, diabetes and increased carotid vascular indices were associated with significantly higher SYNTAX score (SS). In contrast, obese patients revealed a notably lower SS compared to non-obese individuals, which was not explained by the number of CV risk factors or age. All the ultrasound indices (except for visceral fat - IAT) revealed considerable associations with the SS; while the highest correlation coefficient was found for PATIMA combined index. Hence, none of the obesity-related clinical indices showed an association with CAD complexity. Moreover, male sex, chronic kidney disease and the PATIMA index were independently associated with the Syntax Score. Furthermore, the highest sensitivity and specificity in prediction of either SS > 1 or SS > 7 were found for the combined PATIMA index. The findings of this study demonstrated that a combination of ultrasound indices related to peri-arterial fat and vascular wall (PATIMA index) is associated with more complex CAD in high and very-high risk patients. Hence, PATIMA index revealed improved predictive value compared to other single ultrasound indices and clinical risk assessment.