Does a patient with 40% LAD stenosis, prior LCx angioplasty, stented first obtuse marginal, and mid RCA with 75% stenosis and 85% ISR require further intervention?

Management of Coronary Artery Disease with Multiple Stenoses

Based on the patient's coronary angiography findings showing 75% mid RCA stenosis and 85% in-stent restenosis (ISR), further intervention is required to address these hemodynamically significant lesions.

Assessment of Current Coronary Status

• The patient has multiple coronary lesions including:

  • LAD with 40% stenosis (non-obstructive)
  • Previous LCx proximal angioplasty
  • Previous stent in first obtuse marginal proximal segment
  • Previous stent in proximal RCA
  • Mid RCA with 75% stenosis (obstructive)
  • 85% in-stent restenosis (obstructive) 1

• According to CAD-RADS classification, the patient's 75% mid RCA stenosis and 85% ISR would be categorized as CAD-RADS 4A/S, indicating severe stenosis with stent presence 1

• Severe RCA stenosis (70-99%) is considered hemodynamically significant and requires intervention 2

Need for Intervention

• The 75% mid RCA stenosis meets criteria for significant obstructive disease requiring intervention 2

• The 85% in-stent restenosis is classified as severe and warrants treatment 1

• When severe stenosis (>70%) is identified, invasive coronary angiography with potential intervention is recommended 2

• The LAD 40% stenosis is considered non-obstructive and does not require intervention at this time 1

Management Approach

• For the 75% mid RCA stenosis:

  • Percutaneous coronary intervention (PCI) with stent placement is indicated 2
  • Consider functional assessment (FFR) if there is any question about hemodynamic significance 2

• For the 85% in-stent restenosis:

  • Rotational atherectomy with adjunct balloon angioplasty is an effective treatment option 3
  • This approach leads to acute lumen gain through effective plaque removal 3
  • Additional balloon angioplasty after atherectomy provides further lumen gain through stent expansion and tissue extrusion 3

Considerations and Potential Challenges

• The high-grade ISR (85%) has a higher risk of recurrent restenosis 3

• Factors associated with recurrent restenosis include:

  • Lesion and stent length
  • Severity of initial stenosis
  • Acute neointimal recoil after intervention 3

• Close monitoring after intervention is necessary due to the risk of recurrent restenosis 3

• The LAD 40% stenosis should be monitored, especially if high-risk plaque features are present 4

Follow-up Recommendations

• After intervention, regular follow-up is essential to monitor for:

  • Recurrent symptoms
  • Progression of non-obstructive disease (LAD 40%)
  • Recurrent in-stent restenosis 2, 4

• Aggressive medical therapy including:

  • High-intensity statins
  • Dual antiplatelet therapy
  • Risk factor modification 4

• Consider non-invasive functional testing (stress test) at 6-12 months post-intervention to assess for recurrent ischemia 2