A 71-year old diabetic, normotensive, dyslipidemic gentleman was admitted to our hospital due to progressive exertional angina for 1 year. He was a current smoker. His physical examiniation was normal and cardic enzymes were normal. His ECG and chest X-ray were unremarkable. Echocardiography reveals no gross regional wall motion abnormality with LVEF ~63%.

1) Rt. coronary angiography showed diffuse 40-50% stenosis from proximal to mid part of right coronary arery (RCA) and collateral flow to left coronary artery. ( Movie 1)
2) Lt. coronary angiography showed very tight stenosis in distal left main coronary artery (LMCA) to proximal left anterior descending (LAD) with relatively healthy and in the left circumflex (LCX) ostium. Ramus intermedius (RI) had a 80-90% diffuse stenosis. ( Movie 2, Movie 3)

We inserted an intra-aortic balloon pump(IABP) via the left femoral artery for hemodynamic support during intervention; its pumping rate was set at 2:1. Then, a 8 Fr JL3.5 guiding catheter was engaged in left coronary artery through a right femoral approach. An 0.014” BMW guidewire was positioned in the RI branch. And then, LAD was tried with a 0.014” Choice PT wire. RI was sequentially dilated with 2.5/20 mm Black Hawk balloon(Figure 1). IVUS examination showed similar findings with angiography without significant plaque burden in LCX ostium. We planned simple cross-over technique from LM to LAD across LCX. The proximal LAD to LMCA was dilated with Maverick 1.5/20 mm. Because RI was so diffue stenotic, additional dilation was performed with Black Hawk 2.5/20 mm at 10atm. Then, a 3.5/28mm Xience V stent was placed at the proximal LAD to the LMCA at 8atm(Figure 2). A high pressure post-dilation was performed with a 4.0/13 mm Fortis balloon at 18atm(4.15mm)(Figure 3). Thje final angiogram showed that the procedure was successful(Figure 4, Figure 5).