Flow May Decrease With Downstream Lesion
An 83-year-old male patient who was an ex-smoker with a medical history of diabetes mellitus, hypertension, and stage 3 chronic renal impairment presented with intermittent, variable threshold exertional angina for a few weeks. His symptoms persisted despite optimal medical treatment. His vital signs were stable, and his physical exam was unremarkable. An electrocardiogram showed sinus rhythm with T inversions over the anterior leads. An echocardiogram revealed left ventricular ejection fraction of 45-50% with severe hypokinesia over anterior wall.
His coronary angiogram showed moderate ~40-50% stenosis from distal left main artery (LM) to ostial left anterior descending artery (LAD) (Medina 1,1,0) and critical ~99% stenosis over proximal LAD-diagonal bifurcation (Medina 1,1,1) (Figures 1-2). Fractional flow reserve (FFR) was performed with pressure wire at proximal left circumflex artery (LCx), which showed minimal value 0.83 at maximal hyperemia. Calculated Society of Thoracic Surgery score of this gentleman for coronary artery bypass grafting surgery (CABG) was 4.59%. SYNTAX score for LAD-diagonal percutaneous coronary intervention (PCI) was 11, and SYNTAX score for LM and LAD-diagonal PCI was 24.
What is the most appropriate next step in this patient's management?