How do you determine which patients with ICAS are the best candidates for balloon angioplasty versus those who should continue with aggressive medical management alone?

A recent study on JAMA network found angioplasty superior to medical therapy (dual antiplatelet and statin), whereas previous studies have found angioplasty combined with stenting more risky. I am not sure that appropriate guidelines have yet been developed, but I would think that the stenosis must be severe and must be associated with evidence of infarctions within its territory.

I think there is still inadequate evidence to routinely recommend angioplasty over medical management for symptomatic ICAD. I reserve it for:

1. Patients in extremis (severe symptoms with CTP suggesting flow failure as the mechanism of injury compared to baseline CTP). I usually obtain a baseline CTP in patients with the first presentation of symptomatic ICAD.
2. Patients who are unwilling/unable to comply with max medical management (still smoking, not addressing their diet and metabolic syndrome), and thoroughly warning them that stenting is not the best treatment and associated with significant risk.

I think when we recommend "max medical management", it's usually just DAPT, statin, and not smoking with little regard to diet which is the prima...