Thai male 62 years old presenting at emergency department with acute onset retro-sternal chest pain at rest 4 hours prior to hospital. Past history: Hypertension and dyslipidemia, current medications are simvastatin 10 mg 1-tab oral hs and manidipine 20 mg 1 tab oral pcPhysical examination: Vital sign BP 146/70 mmHG., HR 90 bpm, SpO2 98% temp 37.0 CelsiusHeart: normal s1s2 without murmur, Lung: No adventitious sound, Neuro: E4V5M6 well co-operate

EKG was shown Sinus rhythm diffuse ST depression in lead I, II, avL, V2-V6, ST elevation in lead aVRCXR: Normal cardiac contour without lung infiltration or congestionLab: Troponin I 2568 ng/dl, Hb 13 g/dl, Platelet 210,000/ml, INR1.1 Creatinine 0.75 mg/dlEchocardiography: Good LV systolic function (LVEF 67%), Hypokinesia at basal to mid segment of inferior wall, no significant valvular abnormalities, no pericardial effusion, no Aortic root dissection was detected

Right dominantLM : 95%stenosis distal LM (Medina 1:1:0:0)LAD : heavy calcified, subtotal occlusion proximal LAD, Received collateral from RCA Lcx : Nonsignificant stenosisRCA : 40 %stenosis proximal RCA, 50% stenosis mid RCA, gave collateral to LAD

Right femoral approach: 7Fr. Femoral sheath, Heparin 5000 unit was given.Guiding: JL short tip 7Fr. 4.0, Wire: Sion to RI, Turntrac to LAD and Lcx Balloon predilate at LM to LAD and proximal to mid LAD with SC balloon 2.5x15mm inflated to 12 atm.Zotarolimus eluting stent 3.0x22 mm deployed at proximal to mid LAD, inflated to 12 atm.Zotarolimus eluting stent 3.5x22 mm deployed at LM to proximal LAD.POT with balloon stent at LM inflated to 16 atm.Dual lumen catheter was inserted to LAD and re wire with Sion blue open strut to RI and LCxKBI at LM-LAD-LCx bifurcation with balloon stent 3.5x22 mm inflated to10 atm, balloon stent 3.0x20 mm inflated to 10 atm x 2 times.KBI LM-LAD-RI with balloon stent 3.5x22 mm inflated to12 atm and SC balloon 2.5x15 mm inflated to 8 atm.POT at LM with balloon stent 3.5x22mm 20 atm POT with NC balloon 5.0x15 mm 12 atm Stent at LM elongated into aorta, Proximal LAD not fully expand (Longitudinal stent elongation)Dilate ostial LM with NC 5.0x15 mm Inflated 16 atm for 8 sec.Try to compress stent back to the ostial by anchoring balloon in LM. Final angiogram shows no residual stenosis.DES good expansion with elongate DES from LM to Ao, Coronary angiogram was planned next 3 month for evaluate LM stent.
CAG at 3 months with IVUS guide shows ISR 60-65% mid to distal LM.PCI ISR of Left main by IVUS guidance to avoid wiring into side strut of elongate LM stent, and deployed Everolimus eluting stent 40 mm x 12 mm at LM.