61-year-old gentleman with multiple cardiac risk factors like hypertension, diabetes mellitus, chronic kidney disease and ischemic stroke admitted for Non ST elevation myocardial infarction. Echocardiogram showed preserved left ventricular ejection fraction. He had history of stenting to LAD and RCA in 2016 in different setting. 3 coronary angiograms were done subsequently revealed mild ISR of LAD and RCA stent. He had major depressive disorder due to frequent admission for chest pain. 

Right radial approach with EBU 3.5 engaged to left system. Coronary physiology assessment with µFR was not significant at 0.83 for LAD lesion and 0.90 for RCA lesion. FFR was done revealed insignificant result of 0.83. Proceeded with RFR which was significant of 0.88 at resting and huge step up to 0.95 at ISR LAD segment. LAD wired with Sion Blue. IVUS noted mid to distal stent was undersized without significant plaque. LCX wired with runthrough floppy. Distal lesion predilated with scoring balloon 2.5x15 up to 2.56. Proximal stent predilated with cutting balloon 3.5x10 up to 3.78. Mid to distal stent undersized segment prepared with NC balloon 3.0x15 up to 3.17. IVUS run post preparation noted previous stent expanded well and lesion well prepared. Distal lesion deployed with DEB 2.75x15 up to 2.75. DES 3.5x29 deployed at proximal LAD up to LM. LM POT with balloon 5.0 x8. Proximal stent post dilated with NC balloon 4.0x15 and NC balloon 5.0x10. Post procedure IVUS noted stent well expanded and RFR at resting was 0.93. LVEDP guided hydration was used during procedure as well and total contrast usage was 40cc for this complex PCI.

Coronary physiology assessment, LVEDP guided hydration and IVUS guided PCI has successfully compliment this 6th angiogram of patient and  bring a glimpse of light to this depressed patient. There was no longer complain of angina during the 6 months follow up.