A 70-year-old gentleman presented to us for chest pain for around 12 hours. 

Echo Dilated LVImpaired LV systolic function. LVEF 32.5% by Simpson's. Global hypokinesiaSatisfactory RV systolic function Mild AR/ MR/ TRNo pericardial effusion / LV thrombus 
peak CK 800. TnI > 50000

restudy Coro after 6 days LM normal LAD pLAD 80% disease followed by diffuse disease along whole LAD and another 90% lesion over mLAD, calcified vesselsignificant increase Lcx vessel size compared with previous Coro 

Decided for optimisation of LCx/ OM2 bifurcation first noted distal migration of previous dLCx stent, likely pushed down by plain ballon during manipulation angioplasty of the migrated stent with 3.0 and 2.5 ballon. then decided for culotte Stenting at LCx/ OM2 bifurcation with 3.0 stent deployed at m-dLCx then KBA 
PCI to p-mLADOCT show TCFA/ lipid rich plaque, tight stenosis, lesion length around 8mmm-dLAD long and circumferential calcified lesion with tight stenosis  consideration: - poor LVEF and PCI done in Lcx already, not for CABG as risk is high - high risk of no reflow for pLAD plaque but tight lesion to keep medical tx - m-d LAD calcified lesion need to be settled to ensure good stent expansion and prepare for bail out if no reflow 
rotational atherectomy done at p-mLADlesion further predilated with undersized NC balloon 2.5 mLAD stented with 2.5/23 stent and p-mLAD stented with 3.5/23 stent PSHP with 4.0 NC ballon at pLAD, avoid touching the lipid rich lesion, gentle undersize 3.5 NC ballon at p-mLAD, 3.0 and 2.5 NC ballon at mLAD still developed no reflow after PSHP and hypotension given repeated dose of adenoscan with crusade microcatheter mechanism likely related to lipid emboli based on OCT, mechanical thrombectomy with 7Fr thrombuster Pro and penumbra system distal injection with microcatheter confirmed no dissection and no residual stenosis over mLAD. Given repeated dose of adenoscan again Flow improve to TIMI II and haemodynamic stabilized Decided for stage procedure 

TCFA/ lipid rich plaque represent vulnerable lesion, high risk of no reflow of stenting due to lipid emboli complex situation when there are calcified tight lesion distally 
DDx of no reflow post-stenting - embolization (plaque/ thrombus/ air)- thrombosis- dissection - spasm Distal contrast injection with microcatheter and intracoronary imaging might help differentiate the causes  Management of lipid embolization - vasodilator (adenoscan, nicardipine)- aspiration with thrombectomy system