A 70-year-old male was admitted with effort chest pain, which developed 1 year ago and aggravated recently. His coronary risk factors were hypertension and ex-smoking. His ECG and cardiac biomakers were normal. Echocardiography showed a LVEF 64% without regional wall motion abnormality.

1. A right angiogram showed moderate stenosis in the of mid to distal RCA and PDA branch.(Figure 1)
2. A left coronary angiogram (LAO cranial view) showed moderate stenosis in the LAD ostium and diffuse significant stenosis at the bifurcation of the diagonal branch.(Figure 2) The next coronary angiogram (spider view)(Figure 3) showed no ostial disease of the LM but in the AP cranial view, the angiogram showed very severe ostial stenosis.(Figure 4)

A 8 Fr EBU 3.5 with side-hole guiding catheter was engaged into left coronary artery. A 0.014” Floppy BMW guidewire was placed into the LAD and then IVUS imaging was performed. The IVUS showed a large plaque burden with minimal luminal area of 3.5 mm2 at the ostium of LM.(Figure 5) A 4.0 * 18 mm Xience V stent was directly deployed at the ostial lesion followed by adjuctive postdilatation with stent balloon.(Figure 6) An other 0.014” Floppy BMW guide wire was placed into the diagonal branch and then a 3.0 * 28 mm Xience V stent was deployed in the mid LAD across the diagonal branch.(Figure 7) After rewiring the diagonal branch through the stent struts with the same guidewire, the diagonal vessel was dilated with a 2.5 * 15 mm Maverick balloon. A 2.5 * 18 mm Xience stent was deployed with minimal protrusion of proximal stent strut into main branch with a uninflated 3.0 * 18 mm Fortis balloon on the branch and then kissing balloon dilatation was done.(Figure 8) Another 2.5 * 18 mm Xience V stent was deployed in the distal LAD with overlapping.(Figure 9) Additional balloon postdilatation in both branches were performed and final kissing balloon dilatation was performed using 3.0 * 18 mm Fortis balloon in the LAD and 2.5 * 20 mm Dura Star balloon in the diagonal branch.(Figure 10) The LM stent was dilated with a 4.0 * 15 mm Quantum balloon.(Figure 11) Final angiogram and IVUS image showed a good result.( Movie 1, Figure 12)