Physiology-Guided Management of Serial Coronary Artery Disease: A Review.

Importance: Ischemia-guided revascularization is the cornerstone of contemporary management of coronary artery disease and has evolved from noninvasive functional evaluation to real-time assessment with invasive physiological indices during diagnostic catheterization. However, serial/diffuse disease is common, and revascularization decisions often need to be made about individual lesions within the same vessel. It is unclear whether current physiological techniques, such as fractional flow reserve, can be reliably used to discern the individual contribution of lesions within a serially diseased vessel with erroneous measurements, potentially leading to suboptimal revascularization decisions. This review addresses the application of physiological techniques to serial coronary disease, highlighting challenges and potential solutions. Observations: Physiological indices, such as fractional flow reserve, are well validated and correlated with clinical outcomes; however, the challenging physiology of serial stenoses makes it difficult to apply conventional techniques to identify the physiological significance of individual lesions. The 2 methods are most accurate in assessing serial disease are the manual pullback, with treatment of the greatest pressure gradient, or adopting the use of a large disease-free side branch to isolate the significance of the proximal lesion in the context of serial disease involving the left main coronary artery. In addition, resting indices, such as instantaneous wave-free ratio, have theoretical benefits that may make them more reliable in serial disease, with further data awaited. Conclusions and Relevance: Serial coronary artery disease is common, and physiological assessment is prone to errors. The future, whether it be in improving the interpretation of fractional flow reserve, using resting indices such as instantaneous wave-free ratio, or examining novel flow-based resistance indices, will hopefully improve our management of this common yet unresolved clinical conundrum. In the meantime, revascularisation decisions in this challenging scenario should focus on clinical presentation and physiologic evaluation using a pressure-wire pullback maneuver and left main disease-free side branch where appropriate.