A 66 year-old man visited our emergency department with acute chest pain lasting 2 hours (Dec, 2006). Four-years ago (July, 2007), he underwent multiple drug-eluting stents (DES) implantation in mid-to-distal RCA diffuse lesions (Cypher; 3.0X18mm, 3.0X18mm, and 2.75X23mm) (Fig 1, Fig 2). After 2 years later (July 29,2005) after the index procedure, follow-up angiogram CAG showed proximal and distal edge in-stent restenosis (ISR) (Fig 3) and therefore POBA at distal-edge ISR site (Fig 4) and additional long DES stenting (Cypher 3.5X33mm) (Fig 5) at proximal-edge ISR site was performed. However, second follow-up angiogram (Feb, 2006) showed multiple stent fractures at mid and distal portion of RCA stent (Fig 6, Fig 7). At this time, because the patient did not show any subjective and objective ischemia during stress testing, just medical treatment was continued.

Six-months ago (Dec, 2006), he presented acute STEMI even on dual antiplatelet therapy and immediate coronary angiography revealed a total thrombotic occlusion of proximal RCA (Fig 8). After primary balloon angioplasty, TIMI 3 patent flow was obtained (Fig 9, Fig 10). Then, patient had been stable and discharged with triple antiplatelet therapy (aspirin, clopidogrel, and cilostazol).

At this presentation with acute chest pain lasting 2 hours (Jun 14,2007), ECG again showed ST-segment re-elevations in lead II,III,aVF and coronary angiogram showed a total thrombotic occlusion of mid RCA (Fig 11). Balloon angioplasty with voyager 3.0X30mm, Amadeus 3.0X30mm, Ryujin 2.5X15mm balloon was performed (Fig 12) and final angiogram showed a TIMI 3 flow, but consistent multiple stent fractures (Fig 13). This patient discharged and has been followed without further complications until now.