A 57 year-old male was admitted for resting chest pain for 1 month and syncope. 4-months ago, he had got PCI at dLM-pLAD with Xience V 3.5*12mm, pdLCx with Xience V 3.5*12mm. (Figure 1) After PCI, he had been stable but 1 month ago, he felt resting chest pain and the frequency of chest pain has been increased. 2 hours ago, he had syncope for 3 minutes with chest pain and then he was referred to ER. He had medication including aspirin, plavix, beta-blocker and statin regularly for last 4 months and his coronary risk factor was hypertension. Her resting ECG was normal.

1. A right coronary angiogram showed mild stenoses in proximal and mid RCA. ( Movie 1)
2. A left coronary angiogram showed very severe stenosis at LMCA ostium, proximal edge of previous stent (Xience V 3.5*12mm) in dLM-pLAD. ( Movie 2, Movie 3)

Left coronary artery was engaged with an 7Fr JL 4 guiding catheter with side holes. A 0.014” BMW guidewire was crossed into LAD and IVUS catheter was also passed into LAD. IVUS exam showed severe atherosclerosis which was almost encircling IVUS catheter from proximal edge of stent to LMCA ostium. ( Movie 4) We performed FFR at LM, the value was 0.66 at maximum hyperemia with intravenous infusion of adenosine at 140mcg/kg/min.(Figure 2) The proximal edge of stent at LM was treated with direct stenting (Xience V 4.0 x 15 mm) overlapped with previous stent. ( Movie 5, Figure 3) Final angiogram showed a successful stenting at LMCA. ( Movie 6, Movie 7)