A 49-year-old male, presented to the Emergency Room (ER) with chest pain that had persisted for eight hours prior to admission. He was diagnosed with unstable angina pectoris. His vital signs upon arrival at the ER were a blood pressure of 148/92 mmHg and a heart rate of 98 bpm. There were no rales and his peripheral perfusions were normal. Electrocardiography result showed normal sinus rhythm, with ST depression in I, aVL, V5-V6.

Electrocardiography result showed normal sinus rhythm, with ST depression in I, aVL, V5-V6. Echocardiography result showed reduce LV systolic function, LV ejection fraction 44% (Simpson's), akinetic at mid basal inferoseptal, mid basal inferior, hypokinetic at inferolateral, other segments normokinetic. Eccentric LVH with LV diastolic dysfunction grade I. Good cardiac valves. Good RV contractility. Relevant laboratory included hemoglobin level of 12.5 g/dL, creatinine level of 3.43 mg/dL, eGFR 21 mL/min/1.73m².

Normal saline injection for guide the canulation RCA and LCA. ECG monitoring before and after the infusion of a bolus of saline (5-7 ml approximately). The use of 8 mL of saline to push 2 mL of contrast on vertical syringe position to visualized coronary artery. The angiography result showed LM was normal, subtotal stenosis at proximal LAD, stenosis 70% at proximal OM2 and CTO RCA. PCI was planned to the LAD with an IVUS-guided minimal contrast approach.

Use patients previous coronary angiograms is a simple step that can aid operators to navigate through vessels, without the need for further injections. The use of intracoronary wires can aid in marking the important side branches that should be taken into consideration during PCI of the target vessel. Wiring with floppy wire to LAD, LCx and Diagonal 1 as a distal and proximal marker for intervention. This mark of wires serves as a landmark for balloon dilatation. Then, predilated with scoring balloon 3.0 x 20 mm. IVUS showed diffuse lesion with fibrocalcified at proximal LAD, MLA of 3.74 mm2. Lesion preparation was done with scoring balloon 3.0 x 20 mm, stented with DES 3.5 x 38 mm. IVUS showed no medial dissection, stent well apposed and under expanded at proximal stent. Postdilated with NC balloon 4.0 x 10 mm. The procedure was completed without complications. A total of 10 ml of  contrast. He was well at discharge without symptoms.

Chronic kidney disease (CKD) has been identified as a scenario for reduced contrast administration during PCI. Ultra low contrast PCI approach may be helpful. Combination of the IVUS and the understanding of anatomical mapping based on previous angiography and intracoronary wires as a landmarks allow a safer ultra low contrast PCI. IVUS guided PCI can guide to achieve a good outcome in ultra low contrast PCI. IVUS can assess morphology, guide vessel preparation and choose landing zone for stent implantation.