A 50-year-old non-diabetic, normotensive woman was admitted with atypical chest pain at rest for several months. She received PCI to the right coronary artery(RCA) in 2008. Thallium SPECT showed reversible large sized mildly decreased perfusion defect in anterior wall. Treadmill test revealed negative finding.

1) RCA: patent ( Movie 1)
2) LM: normal
3) LAD: intermediate, diffuse disease ( Movie 2)
4) LCX: mild disease (Figure 1)

Although the LAD was angiographically not significant lesion, In order to evaluate the hemodynamic impct of these lesions, we performed fractional flow reserve (FFR) measurement in the LAD. A 0.014” pressure wire was used for the FFR measurement, while hyperemia was induced by intravenous adenosine administration. FFR was 0.73, 0.86 and 0.90 in the mid-LAD, the prox-LAD and the LAD ostium, respectively. We tried to evaluate intravascular ultrasound(IVUS) exam of LAD, but failed to pass IVUS catheter through the mid-LAD due to calcified plaque (Figure 2). Based on the above results we decided to perform angioplasty of the proximal to mid-LAD. The left coronary artery was engaged with a 7 Fr XB 3.5 guiding catheter and 0.014” BMW guidewire was positioned in the LAD. After predilation with a 2.0/15mm IKAZUCHI balloon, we dilated with 2.75/15mm Quantum balloon due to superficial calcification at mLAD (Figure 3). A 2.75/28 mm PROMUS Element stent was deployed at mid-LAD and then 3.0/28 mm PROMUS Element stent was deployed at the proximal LAD sequentially (Figure 4) . High pressure balloon with Quantum 2.75/15 mm was done with a very good final result (Figure 5, Figure 6).