A 74 year-old man visited our outpatient clinics because of multivessel coronary disease on Coronary CT. He did not feel any chest discomfort. However, he has multiple coronary risk factors such as hypertension, diabetes, ex-smoking, hyperlipidemia and previous stroke history. Coronary angiogram showed significant stenosis with ulceration at proximal LAD. So he admitted for intervention.

1. A Left coronary angiogram showed significant stenosis with ulceration at proximal LAD and intermediate lesion at mid LAD. ( Movie 1-1, Movie 1-2)
2. A Right coronary angiogram showed no significant stenosis ( Movie 2)

An 8 Fr sheath was inserted through right femoral artery and another 6 Fr sheath was inserted through the right femoral vein. Left coronary artery was engaged with a JL4 SH 8Fr guiding catheter. First, to evaluate proximal ulcerated lesion and midLAD lesion, virtual histology was performed. VH showed mainly fibrous tissue characteristics. (Figure 1) Then, an intravascular ultrasound (IVUS) (Boston Scientific) was performed. IVUS showed 3.8mm² minimal lumen area (MLA) at pLAD with ulceration and 3.2mm² MLA at mid LAD with diffuse calcified lesion (Figure 2). IVUS and VH demonstrated diffuse fibrocalcific plaque and ulceration across pmLAD. After pressure wire (RADI) insertion, we checked FFR. Baseline FFR was 0.98. Then we induced hyperemia by adenosine 140mcg/kg/min infusion via femoral route. After induction of hyperemia, FFR was 0.89. (Figure 3). And then we performed another functional study, thallium spect, which showed no abnormal perfusion defect. So, instead of performing PCI, we decided to treat medically.