The association between angiographic stenosis characteristics and surgical treatment in diffuse LAD disease

Background Intracoronary pressure-wire pullback allows differentiation between focal and diffuse disease, improving precision of revascularisation strategies. While focal lesions benefit from percutaneous coronary intervention (PCI), diffuse disease yields suboptimal results and is therefore treated with coronary artery bypass grafting (CABG) or conservatively (i.e., optimal medical therapy [OMT]). Current guidelines emphasise the prognostic relevance of proximal left anterior descending artery (LAD) disease, yet its role in guiding treatment in diffuse disease remains uncertain. Objectives To evaluate whether angiographically severe proximal LAD disease influences revascularisation strategy in functionally significant diffuse LAD disease. Methods This retrospective cohort study included patients undergoing coronary angiography and subsequent pullback measurement in the LAD in the presence of ischemia (FFR ≤0.80 or RFR ≤0.89), between 2022 and 2024. Coronary anatomy was reassessed blinded to treatment. Multinomial logistic regression explored predictors of treatment strategy (OMT, PCI, or CABG) in patients with diffuse LAD disease. Results Among 303 patients with significant LAD disease, 214 (71%) had diffuse and 89 (29%) focal disease. Baseline characteristics were similar. Focal disease was more associated with triple-vessel CAD (34% vs. 19%; p = 0.007). Severe proximal (21% vs. 7.9%; p = 0.004) and distal LAD stenosis were more common in diffuse disease. In diffuse disease only, severe proximal LAD was associated with an increase in CABG (28.3% vs. 10.1%; p = 0.004) and a decrease in OMT rates (54.3% vs. 75.6%; p = 0.009). Multinomial regression confirmed this association (OR 0.26; p = 0.003). Conclusion Absence of angiographically severe proximal LAD stenosis is associated with CABG deferral in diffuse, functionally significant LAD disease.