A 78 year old male patient presented with aggravated effort chest pain. His coronary risk factor was smoking. Baseline ECG was normal. Echocardiography showed normal LV function without regional wall motion abnormality.

Coronary angiogram revealed diffuse stenosis at both the left anterior descending artery (LAD) and left circumflex artery (LCX) (Figure 1, Figure 2). The proximal LAD and LCX lesions were extended to both ostiums. Other significant stenosis was seen at the second obtuse marginal (OM) branch. Because the OM lesion is too small to put a stent, we planned to treat both proximal lesions with Cyphers.

An 8F 3.5 JL guiding catheter was engaged at the ostium of the left main coronary artery (LMCA). After guidewire advancement with a Neos 0.014 inch, the LAD lesion was predilated with an Apollo balloon (2.5 X 20 mm) (Figure 3). Another Neos 0.014 guide wire was introduced into the second OM and predilation was performed with the same Apollo balloon (Figure 4). Then, we decided to treat both proximal epicardial lesions with the V stenting for complete lesion coverage. V stenting was performed in the LAD with a 3.0 X 33 mm Cyhpher stent at 20 atm and in the ostial LCX with a 3.0 X 23 mm Cypher stent at 20 atm, sequentially (Figure 5). Final kissing balloon dilatation was performed with both stent balloons. Following angiogram showed well deployed stents at the LAD and LCX (Figure 6, Figure 7). IVUS image revealed very short carina in the distal LMCA and good stent expansion in both branches (Figure 8).