Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions

A diffuse and heavily calcified coronary lesion represents a complex clinical scenario, often leading to suboptimal outcomes. The optimal management, whether percutaneous coronary intervention, surgery, or medical treatment, remains debatable.<b> </b>A 64-year-old male was referred to our outpatient clinic with persistent typical chest pain. Coronary angiography revealed diffuse and heavily calcified lesions with 75% stenosis at the proximal to middle LAD. A physiological assessment was performed using a hybrid approach of resting full-cycle ratio (RFR) and fractional flow reserve (FFR). Initial RFR was inconclusive (0.91). Follow-up FFR measurement supported the indication for stenting. Lesion characterization using intracoronary optical coherence tomography (OCT) showed a thick, long, and heavily calcified lesion with an OCT Calcium score of 4. The minimal lumen area (MLA) was only 1.78 cm² and indicative of stent deployment since the MLA was less than 3 mm². Three runs of rotational atherectomy were performed, followed by non-compliant balloon dilatation and two DES implantations. The procedure was successful with TIMI flow grade 3 and optimal OCT evaluation. The combination of hybrid physiological assessment and intravascular imaging is an effective and efficient strategy for managing complex diffuse-calcified coronary lesions.