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

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The optimal management, whether percutaneous coronary intervention, surgery, or medical treatment, remains debatable. 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." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-1255/v1", "name": "Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary..." } } ] } Home Browse Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Hutomo SA, Luke K, Hernugrahanto AP et al. Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.12688/f1000research.167119.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] Suryo Ardi Hutomo https://orcid.org/0000-0002-0592-3117 1-3 , Kevin Luke https://orcid.org/0000-0003-2160-2927 2,3 , Aldhi Pradana Hernugrahanto 1-3 , I Gde Rurus Suryawan 1-3 , Yudi Her Oktaviono https://orcid.org/0000-0002-2350-2789 1-3 Suryo Ardi Hutomo https://orcid.org/0000-0002-0592-3117 1-3 , Kevin Luke https://orcid.org/0000-0003-2160-2927 2,3 , [...] Aldhi Pradana Hernugrahanto 1-3 , I Gde Rurus Suryawan 1-3 , Yudi Her Oktaviono https://orcid.org/0000-0002-2350-2789 1-3 PUBLISHED 14 Nov 2025 Author details Author details 1 Cardiovascular Subspecialist Study Program, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia 2 Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia 3 Dr. Soetomo General Academic Hospital,, Surabaya, Indonesia Suryo Ardi Hutomo Roles: Conceptualization, Data Curation, Investigation, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Kevin Luke Roles: Project Administration, Software, Writing – Original Draft Preparation, Writing – Review & Editing Aldhi Pradana Hernugrahanto Roles: Data Curation, Project Administration, Writing – Original Draft Preparation I Gde Rurus Suryawan Roles: Data Curation, Validation, Writing – Review & Editing Yudi Her Oktaviono Roles: Formal Analysis, Supervision, Validation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract 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. 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 cm 2 and indicative of stent deployment since the MLA was less than 3 mm 2 . 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. READ ALL READ LESS Keywords Complex Lesion, Intravascular Imaging, Invasive Physiological Assessment, Non-Hyperaemic Index, Case Report. Corresponding Author(s) Yudi Her Oktaviono ( [email protected] ) Close Corresponding author: Yudi Her Oktaviono Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Hutomo SA et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Hutomo SA, Luke K, Hernugrahanto AP et al. Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.12688/f1000research.167119.1 ) First published: 14 Nov 2025, 14 :1255 ( https://doi.org/10.12688/f1000research.167119.1 ) Latest published: 14 Nov 2025, 14 :1255 ( https://doi.org/10.12688/f1000research.167119.1 ) Introduction Complex coronary lesions, particularly those involving calcification and diffuse lesions, remain a common challenge in the management of coronary artery disease (CAD). Calcification increases the rigidity of atherosclerotic plaques and adds technical complexity to revascularization procedures. Heavy calcification increases the risk of complications during and after PCI, including stent under-expansion, uncertain landing zones, the use of multiple stents, and vessel dissection or perforation. These complications potentially result in stent thrombosis, restenosis, myocardial infarction, and increased mortality. 1 Diffuse lesion also increase the complexity of PCI procedures and are associated with poor prognosis. According to angiography findings, diffuse lesion is defined as a long coronary segment (20 mm or above) with angiographic abnormalities without clear focal stenosis. Dealing with diffuse lesions is very challenging since diffuse lesions have a higher incidence of stent malapposition, edge dissection, and underexpansion. 2 Hence PCI with imaging guidance is required with careful consideration of stent usage to avoid over-stenting. 3 Achieving optimal PCI outcomes can be challenging, necessitating adequate lesion preparation and modification techniques before intervention. Given these difficulties and associated risks, the optimal treatment approach—whether PCI, surgical revascularization, or medical treatment—remains a topic of debate. We reported a method for managing a complex diffuse-calcified lesion in the LAD using a combination of hybrid physiological assessment with intravascular imaging. Case presentation A 64-year-old male was referred to our outpatient clinic with persistent typical chest pain. The patient was diagnosed with unstable angina 3 months before and had a history of coronary artery disease with hypertension for 5 years. Physical and laboratory findings were unremarkable. The ECG showed normal sinus rhythm with poor R wave progression. Left ventricular ejection fraction (LVEF) was 68%. The coronary angiography revealed diffuse and heavily calcified lesions extending from the proximal to middle left anterior descending (LAD) artery with 75% stenosis at the proximal segment. The left circumflex artery (LCx) showed a non-significant lesion and the right coronary artery (RCA) appeared normal. We proceeded with a physiological assessment using the resting full-cycle ratio (RFR) and showed a negative result of 0.91. While the confirmatory fractional flow reserve (FFR) showed a significant lesion of 0.76 ( Figure 1 ). Figure 1. Stenosis at the proximal-mid LAD. Intracoronary OCT showed a heavily calcified lesion with a total length of 64 mm, a proximal diameter of 3.5 mm, a distal diameter of 3.0 mm, a percentage area stenosis (%AS) of 79.7%, and a minimal lumen area (MLA) of 1.78 mm 2 ( Figure 2 ). The calcification was thick (0.78 mm) and circumferential with an arc of almost 270 ° . The overall OCT Calcium score was 4. Figure 2. Lesion characterization using OCT. Based on these findings, we planned to perform an atherectomy and implant two stents. Transradial access was obtained using a 6F sheath and an EBU 3.5 6F guiding catheter. The LAD lesion was crossed with a Runthrough Hypercoat, followed by Microcatheter and RotaWire Extra Support. Rotational atherectomy was performed at the proximal and mid-LAD using 1.75 mm RotaBurr at 160.000-190.000 rpm. After three runs, the lesion was expanded using Sapphire NC Balloon 2.75 x 18 mm. The first stent was deployed to mid-distal LAD using DES Xlimus 3.0 x 32 mm at 14 atm, followed by the second stent to proximal-mid LAD using DES Angiolite 3.5 x 34 mm at 18 atm. Evaluation angiography was adequate with TIMI flow grade 3. The evaluation OCT confirmed optimal stent apposition and expansion (MLA of 6.45 mm 2 ) without any medial edge dissection ( Figure 3 ). Figure 3. Evaluation using angiography and OCT showed optimal outcome. Discussion This case illustrates the clinical dilemmas of revascularization decisions and strategies in moderate lesions with diffuse and heavy calcification at the LAD. The first dilemma was the decision to revascularize. The second dilemma was the discordance of the physiological assessment results using RFR and FFR, making the decision more problematic. The decision to revascularize for CAD is based on symptoms and survival improvement. Revascularization is indicated for those with refractory angina despite optimal medical treatment and suitable anatomic conditions, including left main disease or LV dysfunction. The current guideline on coronary revascularization highlighted the uncertain benefit of revascularization in stable ischemic heart disease with preserved LVEF, even when significant proximal LAD stenosis is present. 4 Based on these recommendations, the indication and decision for revascularization for our case is unclear and doubtful. However, medical therapy alone is often insufficient to optimally treat calcified lesions. Standard coronary angiography frequently underestimates the extent and severity of coronary calcification, thereby limiting its reliability for PCI planning. Physiological assessment can aid in determining the necessity of stenting in such lesions by evaluating the hemodynamic condition. Two major coronary physiological indexes are hyperemic and non-hyperemic pressure ratios (NPHR). The use of hyperemic index, FFR, obligates the use of vasodilators such as adenosine. This can lead to additional side effects, complications, and patient discomfort. Performing FFR also requires extra procedural steps and dedicated pressure-sensing guidewires, which increase both procedural time and cost. Hence, more NPHR indexes have been developed and showed non-inferior results to FFR. In 2018, Resting Full-cycle Ratio (RFR) was introduced and validated as a novel non-hyperaemic physiological index. Unlike FFR, RFR does not require vasodilators and limits procedural time with maintained high diagnostic equivalence to FFR (85%). RFR also measures the entire cardiac cycle to determine the lowest distal-to-proximal pressure ratio, which may reduce the operator-dependent bias. 5 , 6 Despite its potential, a study showed that RFR and FFR had discordance for up to 21%. Two major variables associated with this discordance include clinical-anatomical variations and physiological problems ( Table 1 ). 7 In this case, we considered the diffuse lesion at the proximal LAD might be the cause of the discordance. The discordance was more prevalent in the lesion at the LAD (70.5% vs 53.1%, p < 0.001). Under univariate analysis, lesions at the LAD were also associated with discordance (OR = 2.11, 95%CI = 1.51-3.02). 8 Cut-off value for RFR might also cause the discordance. Since there was no universal cut-off value for RFR, we adopted the cut-off value from the validation study (VALIDATE RFR Study) with the optimal cut-off value of ≤0.89. This cut-off had a diagnostic accuracy of 78%, a sensitivity of 85%, and a specificity of 69% compared to FFR with a cut-off value of ≤0.80. 5 Table 1. Factors associated with FFR/NPHR discordance. 7 Clinical and anatomical conditions Physiological problems • Age, sex, body surface area • Diabetes Mellitus, hypertension, chronic kidney disease (and hemodialysis) • Heart failure, impaired LVEF and LVEDP, high BNP levels • Stenosis characteristics (severity, length, focal/diffuse pattern) • Severe aortic stenosis • Arterial stiffness/peripheral vascular disease • Microvascular dysfunction • Resting and hyperemic flow/velocity • Inadequate hyperemia (microvascular vasodilatation, insufficient adenosine) • Cut-off value The discordance between the FFR and NPHR index may complicate clinical decisions to do PCI or not. Deferring intervention in such cases is associated with a worse risk of 5-year vessel-oriented composite outcomes. In our case, we decided to adopt a hybrid approach of RFR and FFR by Casanova et al. ( Figure 4 ), which increased the agreement with FFR to 95% and reduced the need for vasodilators by 58%. 9 According to this strategy, the RFR value of our patient was indeterminate (0.91), yet the follow-up FFR measurement was 0.76 and indicated for intervention. Figure 4. Hybrid RFR-FFR strategy. 9 OCT has become more essential in PCI planning due to its ability to produce high-resolution visualization of calcium morphology, including calcium circumferential arc, thickness, and length. A study concluded that calcified lesions with a circumferential arc >180°, maximum thickness >0.5 mm, and length >5 mm are associated with poor stent expansion. 10 Our patient had a lesion arc of 270°, a maximum thickness of 0.78 mm, and a length of 64 mm. Based on these characteristics, the stent expansion would be suboptimal. Therefore, aggressive calcium modification techniques such as atherectomy are required. Besides lesion characterization, OCT can also support the decision to revascularize by measuring MLA and %AS. An MLA less than 3.1 mm 2 or %AS above 61% has been associated with an FFR below 0.80 with good sensitivity and specificity. A combination of these parameters was also associated with a significantly higher risk of major adverse cardiac events among patients with FFR-negative who did not undergo revascularization (33.3% vs 9.8%, p = 0.040). 11 Based on this data, the MLA and %AS of our patient were indicative of revascularization. This highlights the expanded utility of OCT, not only for lesion characterization but also as an integrated tool for revascularizing decisions in cases of discordance. Conclusions Combining physiological assessment using a hybrid RFR–FFR strategy with OCT imaging is effective and efficient in managing diffuse and heavily calcified coronary lesions. The integrated approach enabled precise lesion assessment, optimal preparation, and successful stent deployment. Patient perspective Combining physiological assessment using a hybrid RFR–FFR strategy with OCT imaging is effective. Consent Written informed consent for publication of his clinical details and/or clinical images was obtained from the patient. Data availability Figshare: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions. https://doi.org/10.6084/m9.figshare.30154813.v2 12 The project contains the following extended data: • Supplementary File 1. (CARE Checklist) Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). References 1. McInerney A, Hynes SO, Gonzalo N: Calcified Coronary Artery Disease: Pathology, Prevalence, Predictors and Impact on Outcomes. Interv Cardiol (London, England). 2025; 20 : e02. PubMed Abstract | Publisher Full Text | Free Full Text 2. Ohashi H, Mizukami T, Sonck J, et al. : Intravascular Imaging Findings After PCI in Patients With Focal and Diffuse Coronary Artery Disease. J. Am. Heart Assoc. 2024 Mar; 13 (5): e032605. PubMed Abstract | Publisher Full Text | Free Full Text 3. Scarsini R, Fezzi S, Leone AM, et al. : Functional Patterns of Coronary Disease: Diffuse, Focal, and Serial Lesions. JACC Cardiovasc. Interv. 2022 Nov; 15 (21): 2174–2191. Publisher Full Text 4. Lawton JS, Tamis-Holland JE, Bangalore S, et al. : 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J. Am. Coll. Cardiol. 2022; 79 (2): e21–e129. PubMed Abstract | Publisher Full Text 5. Svanerud J, Ahn J-M, Jeremias A, et al. : Validation of a novel non-hyperaemic index of coronary artery stenosis severity: the Resting Full-cycle Ratio (VALIDATE RFR) study. EuroIntervention J Eur Collab with Work Gr Interv Cardiol Eur Soc Cardiol. 2018 Sep; 14 (7): 806–814. Publisher Full Text 6. Lee O-H, Roh JW, Kim Y, et al. : Invasive physiologic assessment of coronary artery stenosis by resting full-cycle ratio and fractional flow reserve: a prospective observational study. Sci. Rep. 2023; 13 (1): 15783. PubMed Abstract | Publisher Full Text | Free Full Text 7. Alfonso F, Rivero F: Hyperemic and non-hyperemic indexes in coronary physiology. Causes and implications of discordant results. International journal of cardiology. Heart & vasculature. Ireland. 2023; 47 : 101225. Publisher Full Text 8. Scoccia A, Neleman T, Ziedses des Plantes AC, et al. : Predictors of discordance between fractional flow reserve (FFR) and diastolic pressure ratio (dPR) in intermediate coronary lesions. Int. J. Cardiol. Hear. Vasc. 2023 Aug; 47 : 101217. Publisher Full Text 9. Casanova-Sandoval J, Fernández-Rodríguez D, Otaegui I, et al. : Usefulness of the Hybrid RFR-FFR Approach: Results of a Prospective and Multicenter Analysis of Diagnostic Agreement between RFR and FFR-The RECOPA (REsting Full-Cycle Ratio Comparation versus Fractional Flow Reserve (A Prospective Validation)) Study. J. Interv. Cardiol. 2021; 2021 : 5522707. 10. Fujino A, Mintz GS, Matsumura M, et al. : A new optical coherence tomography-based calcium scoring system to predict stent underexpansion. EuroIntervention J Eur Collab with Work Gr Interv Cardiol Eur Soc Cardiol. 2018 Apr; 13 (18): 2182–2189. Publisher Full Text 11. Vergallo R, Lombardi M, Kakuta T, et al. : Optical Coherence Tomography Measures Predicting Fractional Flow Reserve: The OMEF Study. J. Soc. Cardiovasc. Angiogr. Interv. 2024; 3 (4): 101288. PubMed Abstract | Publisher Full Text 12. Hutomo SA, Luke K, Hernugrahanto AP, et al. : Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions. figshare. 2025 [cited 2025 Sep 18]. Reference Source Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 14 Nov 2025 ADD YOUR COMMENT Comment Author details Author details 1 Cardiovascular Subspecialist Study Program, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia 2 Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia 3 Dr. Soetomo General Academic Hospital,, Surabaya, Indonesia Suryo Ardi Hutomo Roles: Conceptualization, Data Curation, Investigation, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Kevin Luke Roles: Project Administration, Software, Writing – Original Draft Preparation, Writing – Review & Editing Aldhi Pradana Hernugrahanto Roles: Data Curation, Project Administration, Writing – Original Draft Preparation I Gde Rurus Suryawan Roles: Data Curation, Validation, Writing – Review & Editing Yudi Her Oktaviono Roles: Formal Analysis, Supervision, Validation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 14 Nov 2025, 14:1255 https://doi.org/10.12688/f1000research.167119.1 Copyright © 2025 Hutomo SA et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Hutomo SA, Luke K, Hernugrahanto AP et al. Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.12688/f1000research.167119.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 14 Nov 2025 Views 0 Cite How to cite this report: Nastouli KM. Reviewer Report For: Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.5256/f1000research.184202.r448252 ) The direct URL for this report is: https://f1000research.com/articles/14-1255/v1#referee-response-448252 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Jan 2026 Kassiani Maria Nastouli , Department of Medicine, Division of Cardiology, University Hospital of Patras, Rio, Greece Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.184202.r448252 We thank the authors for this case report. This clinical case reports a common and clinically challenging scenario, that being diffuse, heavily calcified lesions with discordance in physiology. The hybrid FFR/RFR with OCT assessment initiative for lesion characterization, calcium modification ... Continue reading READ ALL We thank the authors for this case report. This clinical case reports a common and clinically challenging scenario, that being diffuse, heavily calcified lesions with discordance in physiology. The hybrid FFR/RFR with OCT assessment initiative for lesion characterization, calcium modification planning and post stent optimization highlights how the combination of physiology and imaging can reinforce angiography, helping operators decide on the strategy of revascularization and how to prepare and optimize complex lesions. This case is relevant and has good educational potential. However there are some inconsistencies that need to be revised. 1)Is the background of the case’s history and progression described in sufficient detail? Partly. The report summarizes the key clinical features but the clinical context is not described in enough detail to justify the management pathway. Was there any prior diagnostic testing, how was the prior unstable angina treated, what is the frequency of the symptoms and how did the operators decide on proceeding with coronary angiography. Clarifying these questions will help other operators more on decision-making. 2)Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes 3)Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly. The discussion provides a helpful rationale for the hybrid RFR–FFR approach and OCT-based calcium assessment in diffuse calcified disease. To strengthen clinical interpretability, please distinguish whether the revascularization decision was driven primarily by symptom relief vs prognostic benefit and ensure the guideline discussion is consistent with the patient’s clinical syndrome at presentation. 4)Is the case presented with sufficient detail to be useful for other practitioners? Yes Some extra recommendations. 1. Please correct MLA unit in the Abstract, It is stated that MLA was 1.78cm 2 , while the correct unit would be mm 2 2. The minimum lumen area post PCI is correctly stated as Minimum stent area (MSA). Please correct it. 3, The use of the term "circumferential" would be more appropriate if the arc was 360 degrees. It would be advised to re-phrase it as e.g. large arc or near circumferential 4. Please re-evaluate the abbreviation used in the manuscript. State the full name once and then use the abbreviation in the rest of the manuscript e.g. in the introduction LAD is not fully stated. Addressing these inconsistencies will substantially improve interpretability and make the report more helpful for other physicians Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Coronary artery disease interventions, imaging modules and physiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Nastouli KM. Reviewer Report For: Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.5256/f1000research.184202.r448252 ) The direct URL for this report is: https://f1000research.com/articles/14-1255/v1#referee-response-448252 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Chen X. Reviewer Report For: Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.5256/f1000research.184202.r436545 ) The direct URL for this report is: https://f1000research.com/articles/14-1255/v1#referee-response-436545 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 Dec 2025 Xiang Chen , Xiamen University, Xiamen, China Approved VIEWS 0 https://doi.org/10.5256/f1000research.184202.r436545 This case report describes a 64-year-old male patient with a complex coronary artery disease involving diffuse and severe calcification of the left anterior descending artery (LAD). The author successfully guided and implemented percutaneous coronary intervention by combining physiological assessments ... Continue reading READ ALL This case report describes a 64-year-old male patient with a complex coronary artery disease involving diffuse and severe calcification of the left anterior descending artery (LAD). The author successfully guided and implemented percutaneous coronary intervention by combining physiological assessments such as resting full-cycle ratio (RFR), fractional flow reserve (FFR), and optical coherence tomography (OCT) with vascular imaging techniques. This case highlights the importance of multimodal assessment in the management of complex coronary artery diseases and has certain clinical teaching and practical significance. Advantages Clinical value: The selected cases are representative. Diffuse calcification lesions are a current challenge in interventional cardiology. This report provides practical clinical guidance for handling similar cases. Method integration: The author employed the "RFR-FFR hybrid strategy" in combination with OCT assessment, demonstrating the current trend in modern interventional cardiology of emphasizing both physiological and anatomical evaluations. Comprehensive presentation: The text is accompanied by imaging images (OCT, angiography), which enhances the visualization and persuasiveness of the case. In-depth discussion: The possible reasons for the inconsistency between RFR and FFR results were analyzed, and relevant literature was cited to support the analysis, demonstrating the author's ability in literature research. The structure is clear: it conforms to the basic structure of a case report, with a coherent logic and fluent language. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Coronary Artery Intervention Imaging I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Chen X. Reviewer Report For: Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.5256/f1000research.184202.r436545 ) The direct URL for this report is: https://f1000research.com/articles/14-1255/v1#referee-response-436545 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 14 Nov 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 1 14 Nov 25 read read Xiang Chen , Xiamen University, Xiamen, China Kassiani Maria Nastouli , Division of Cardiology, University Hospital of Patras, Rio, Greece Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Nastouli K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Jan 2026 | for Version 1 Kassiani Maria Nastouli , Department of Medicine, Division of Cardiology, University Hospital of Patras, Rio, Greece 0 Views copyright © 2026 Nastouli K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions We thank the authors for this case report. This clinical case reports a common and clinically challenging scenario, that being diffuse, heavily calcified lesions with discordance in physiology. The hybrid FFR/RFR with OCT assessment initiative for lesion characterization, calcium modification planning and post stent optimization highlights how the combination of physiology and imaging can reinforce angiography, helping operators decide on the strategy of revascularization and how to prepare and optimize complex lesions. This case is relevant and has good educational potential. However there are some inconsistencies that need to be revised. 1)Is the background of the case’s history and progression described in sufficient detail? Partly. The report summarizes the key clinical features but the clinical context is not described in enough detail to justify the management pathway. Was there any prior diagnostic testing, how was the prior unstable angina treated, what is the frequency of the symptoms and how did the operators decide on proceeding with coronary angiography. Clarifying these questions will help other operators more on decision-making. 2)Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes 3)Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly. The discussion provides a helpful rationale for the hybrid RFR–FFR approach and OCT-based calcium assessment in diffuse calcified disease. To strengthen clinical interpretability, please distinguish whether the revascularization decision was driven primarily by symptom relief vs prognostic benefit and ensure the guideline discussion is consistent with the patient’s clinical syndrome at presentation. 4)Is the case presented with sufficient detail to be useful for other practitioners? Yes Some extra recommendations. 1. Please correct MLA unit in the Abstract, It is stated that MLA was 1.78cm 2 , while the correct unit would be mm 2 2. The minimum lumen area post PCI is correctly stated as Minimum stent area (MSA). Please correct it. 3, The use of the term "circumferential" would be more appropriate if the arc was 360 degrees. It would be advised to re-phrase it as e.g. large arc or near circumferential 4. Please re-evaluate the abbreviation used in the manuscript. State the full name once and then use the abbreviation in the rest of the manuscript e.g. in the introduction LAD is not fully stated. Addressing these inconsistencies will substantially improve interpretability and make the report more helpful for other physicians Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Coronary artery disease interventions, imaging modules and physiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Nastouli KM. Peer Review Report For: Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.5256/f1000research.184202.r448252) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1255/v1#referee-response-448252 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Chen X. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 Dec 2025 | for Version 1 Xiang Chen , Xiamen University, Xiamen, China 0 Views copyright © 2026 Chen X. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This case report describes a 64-year-old male patient with a complex coronary artery disease involving diffuse and severe calcification of the left anterior descending artery (LAD). The author successfully guided and implemented percutaneous coronary intervention by combining physiological assessments such as resting full-cycle ratio (RFR), fractional flow reserve (FFR), and optical coherence tomography (OCT) with vascular imaging techniques. This case highlights the importance of multimodal assessment in the management of complex coronary artery diseases and has certain clinical teaching and practical significance. Advantages Clinical value: The selected cases are representative. Diffuse calcification lesions are a current challenge in interventional cardiology. This report provides practical clinical guidance for handling similar cases. Method integration: The author employed the "RFR-FFR hybrid strategy" in combination with OCT assessment, demonstrating the current trend in modern interventional cardiology of emphasizing both physiological and anatomical evaluations. Comprehensive presentation: The text is accompanied by imaging images (OCT, angiography), which enhances the visualization and persuasiveness of the case. In-depth discussion: The possible reasons for the inconsistency between RFR and FFR results were analyzed, and relevant literature was cited to support the analysis, demonstrating the author's ability in literature research. The structure is clear: it conforms to the basic structure of a case report, with a coherent logic and fluent language. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Coronary Artery Intervention Imaging I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Chen X. Peer Review Report For: Case Report: Seeing-is-Believing: Integrating Physiology and Intracoronary Imaging for Resolving the Revascularization Conundrum of Diffuse and Calcified Coronary Lesions [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2025, 14 :1255 ( https://doi.org/10.5256/f1000research.184202.r436545) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-1255/v1#referee-response-436545 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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