A 68-year old man was admitted to our hospital presenting effort chest pain for 1 month. His coronary risk factors were hypertension and smoking. His baseline ECG and echocardiography showed normal findings.

1. Left coronary angiogram showed a significant stenosis at distal left main coronary artery (LMCA) and proximal left anterior descending artery (LAD) bifurcation sites and diffuse narrowing at proximal to distal left circumflex artery (LCX). (Figure 1, Figure 2, Figure 3).
3. Right coronary angiogram showed subtotal narrowing at proximal right coronary artery (RCA) and diffuses stenosis at distal RCA (Figure 4).

Proximal and distal RCA lesions were treated with 2 Cypher stents.

After engaging of an 8F JL 3.5 guiding catheter, a 0.014 inch Choice PT wire was introduced into the LAD and the first diagonal branch (D1) sequentially. After predilation, 2 Cypher stents (3.0 x 23 mm in LAD and 2.5 x 23 mm in D1) were positioned for crushing technique (Figure 5). The side-branch stent is deployed first and the guide wire was removed. Then, the stent in the main branch was expanded to crush the protruding strut of the side branch stent against the main vessel wall. After then, additional high pressure ballooning at the LAD was performed to prevent the recrossing of D1 guidewire into gaps between the three layers of floating stents proximal to the bifurcation or partially crushed stents and stent-uncovered vessel wall. Then, final kissing balloon dilatation was performed with a Blackhawk balloon (3.0 x 20mm upto 3.21mm, 16atm) in LAD and a Ryujin balloon (2.5 x 20mm upto 2,74mm, 14atm) in D1. Coronary angiogram showed no residual in-stent narrowing in both branches (Figure 6).

After then, a 0.014 inch Soft wire was introduced into the LCX. Distal LCX lesion was treated with 1 Cypher stents (2.75 x 33mm). After predilation, additional 2 Cypher stents (3.5 x 23 mm in LM-LAD and 3.0 x 28 mm in LM-LCX) were positioned for crushing technique (Figure 7). The LM-LCX stent is deployed first and the guide wire was removed. Then, the stent in LM-LAD was expanded to crush the stent of the LM-LCX stent. After recrossing with a 0.014 inch Choice PT wire into LCX, final kissing balloon dilatation was performed with a Apollo balloon (3.5 x 20mm upto 4.11mm, 18atm) in LM-LAD and a Maverick balloon (3.0 x 20mm upto 3.23, 17atm) in LM-LCX. Final angiogram showed good results (Figure 8, Figure 9, Figure 10). Six-month follow-up angiogram showed patent all stents (Figure 11, Figure 12, Figure 13).