A 51 year-old male was presented with effort-related chest pain for 1 month. He had a history of hyperlipidemia and was ex-smoker. His resting ECG showed T wave inversion in precordial leads and thallium SPECT revealed partially reversible large sized moderately decreased perfusion in LAD territory.

1. A right coronary angiogram showed intermediate stenoses in proximal and mid RCA.(Figure 1)
2. A left coronary angiogram showed severe stenosis in distal LCX and subtotal occlusion distal to OM2 branch. LAD had diffuse tandem stenosis in prox-to-mid LAD. (Figure 2, Figure 3)

We planned to correct the LAD and LCX lesions because the FFR value in distal RCA was 0.87 at maximum hyperemia with intravenous infusion of adenosine at 140mcg/kg/min. Left coronary artery was engaged with an 8Fr JL 4 guiding catheter with side holes and LAD was crossed with a 0.014” BMW guidewire. IVUS exam revealed diffuse severe atherosclerosis with relatively normal segment between the two stenosis in proximal and mid LAD. (Figure 4) During maximum hyperemia, the pressure wire was slowly pulled back from the distal coronary artery to the ostium of the coronary artery, thereby recording the pressure drop (△ pressure) across each of the individual stenosis during intravenous adenosine infusion. FFR values in the proximal and in distal LAD stenosis were 0.83 and 0.44 after adenosine infusion, respectively. The △ pressure of distal stenosis was greater than the proximal △ pressure. (Figure 5) So, we decided to treat first the distal stenosis and then re-assess with FFR for the proximal stenosis. The more severe stenosis in mid LAD was treated with pre-ballooning (Black Hawk 2.5 x 20mm) and stenting (Xience V 2.75 x 28 mm).(Figure 6) FFR value in mid LAD after correction of distal stenosis was 0.73 that was still significant.(Figure 7) The proximal stenosis was treated with an another 3.5 x 23 mm Xience V stent with overlap and optimized using stent balloon and Dura Star 3.0 x 15mm. (Figure 8)
The LCX lesions was so tight and treated with a 2.75 x 28mm Xience V stent.(Figure 9) Final angiogram showed a good result with TIMI 3 flow.(Figure 10)