Angiographically Successful PCI: Does the Lily Need Gilding?
A 74-year-old woman presented with worsening exertional dyspnea over the preceding 2 months in the setting of severe calcific aortic stenosis. She had multiple comorbidities including severe chronic obstructive pulmonary disease, history of nephrectomy and ileocolectomy for asynchronous tumors, pulmonary embolism, and rheumatoid arthritis on chronic immunosuppression. After multidisciplinary discussions, she was found to be at high surgical risk and planned for transcatheter aortic valve replacement.
Pre-procedural coronary angiography showed unobstructed coronaries but a focal calcific lesion in the left circumflex artery (LCx) with a dual residual lumen (Figure 1). In view of the unusual angiographic findings, the lesion was evaluated further by optical coherence tomography (OCT) imaging and coronary physiologic assessment. The instantaneous wave-free ratio (iFR) was severely depressed at 0.44 in the distal LCx, with an abrupt gradient at the level of the abnormality (Figure 2).
Given the severe, large-territory ischemia, the decision was made to proceed with percutaneous coronary intervention (PCI). The lesion was pre-dilated with a 2.5 mm balloon, and a 3.0 x 15 mm drug-eluting stent was placed, covering the ostium of the obtuse marginal (OM) branch. The stent was post-dilated using a 3.0 mm non-compliant balloon at high pressures (20 atm) with good angiographic result in the main vessel but moderate 40% stenosis of the OM ostium (Figure 3).
What is the next best step in this patient's treatment?