Tandem Coronary Artery Lesions: The Dilemma

A 70-year-old male patient with a medical history of hypertension, hyperlipidemia, and prostate cancer status post-prostatectomy is having dyspnea on exertion for the past 1 month. An echocardiogram was done showing normal left ventricular ejection fraction and no significant valvular abnormalities. The patient subsequently had a nuclear stress test that identified decreased uptake with reversibility in the distal anterolateral and inferoapical walls. Given these findings, the patient was referred for cardiac catheterization. He was found to have double vessel disease: 90% stenosis of the distal left circumflex and tandem lesions in the left anterior descending artery (LAD) with 70% stenosis of the proximal segment and 75% of the distal segment. A drug-eluting stent was placed in the distal circumflex, and the patient was scheduled for staged percutaneous coronary intervention. On follow-up procedure, an instantaneous wave-free ratio (iFR) was performed on the LAD with a distal value of 0.38.

What is the best next step in managing this patient?

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