A 45- years old man was admitted for coronary angiography to evaluate his effort chest pain started 3-months ago. 1 month before admission, He did coronary CT in out- patient clinic due to his symptom, but the result showed that there was no significant stenosis except focal calcification. We did treadmill test after coronary CT, the result was positive in stage 2.

Minimal stenosis with severe tiny calcified plaque at LM and mild stenosis with nodular calcified and non-calcified plaque at pLAD to mLAD were detected. Minimal stenosis with nodular calcified plaque at LCx os and small vessel disease with non-calcified plaque at dLCX were also shown.(Figure 1, Figure 2)

Lt. Coronary angiography shows tight stenosis with ulceration at distal LM and total occlusion at distal left circumflex artery. ( Movie 1, Movie 2, Movie 3).

The left coronary artery was engaged with a 7Fr JL4 guiding catheter, and 2 BMW guide-wires were positioned in the LAD and LCX arteries. From IVUS exam, It was revealed ruptured plaque and heavy superficial calcification at dLM (Figure 3). After predilation with a 2.5x15mm Maverick balloon at pLAD to dLM, a 4.0x23mm Xience was deployed and high pressure ballooning with Sapphire NC 4.0*15mm were done (Figure 4, Figure 5). Post procedure IVUS showed good apposition and adequate stent expansion. Final angiography shows excellent deployment of the stent covering dLM with TIMI III flow.