A 94-year-old man with a history of type 2 diabetes, stage III chronic kidney disease, hypertension, and hyperlipidemia presented to the emergency department with worsening chest pain and tightness that had persisted for several minutes. The electrocardiogram (ECG) revealed ST-segment depression in leads V2-V4(no elevated at V7-V9),, and elevated cardiac enzymes were noted. The catheterization (CATH) lab was promptly activated for non-ST-segment elevation myocardial infarction (NSTEMI)

Hemoglobin: 14.5 g/dLPlatelet: 161 10^3/uLCreatine: 2.0 mg/dLGlucose: 156 mg/dL Creatine kinase(CK): 280 U/LHigh sensitive Troponin I(hs TnI): 2001 pg/mLN-terminal pro-brain natriuretic peptide (NT-Pro-BNP): 487.4 pg/mL

1.LMCA: patent2.LAD:  -P/3 to D/3: diffuse lesion, max 80-90% stenosis  -DB osmium: discrete lesion, max 70% stenosis  DB M/3: diffuse lesion, max 80-90% stenosis3.LCX  - Osmium: 80% stenosis  - P/3:near total occlusion, receiving collateral flow form LAD4.RCA  - D/3: tubular lesion, max 80-90% stenosis before bifurcation   - PDA osmium-M/3: diffuse lesion, max 80-90% stenosis  - PL: diffuse lesion, max 80% stenosis

Staged PCI was performed for complete revascularization. 1^st PCI on the day he arrived ER.CAG revealed total occlusion at LCx and significant stenosis at LAD and RCA, LCx lesion was POBA with 1.5 mm balloon then LCx flow was TIMI3. IVUS showed diffuse atheroma and 180 degree calcification. Then we stop the procedure due to patient can’t cooperate. 2^nd PCI done three days later.After IVUS evaluation, LCx lesion dilated by 2.5 mm cutting balloon and NC balloon followed by LAD lesion also be pre-dilated. Culotte stenting at LM bifurcation with 3.5x23 mm DES to LCX and 3.0x24 mm DES to LAD. Distal LCx and middle LAD lesions both stented by DES also. 3^rd PCI done two months laterDistal RCA to PDA stented by 3.0x28 mm DES and kissing balloon inflation done on distal RCA bifurcation by IVUS guide after predilated the PDA lesion by cutting balloon. Then FFR showed good result>0.8 at distal PDA, PL, LCx but 0.79 at distal LAD. Then we performed POBA at distal LAD lesion.

This patient was of advanced age and had multiple chronic diseases, but he could still take care of himself. Coronary artery bypass grafting (CABG) was not considered due to his old age. Therefore, we performed a complicated complete triple-vessel revascularization with adequate sizing using intravascular ultrasound (IVUS) and checked the final result with fractional flow reserve (FFR). Due to his chronic kidney disease (CKD) and old age, the entire procedure was separated into three stages to reduce the contrast amount and procedure time at each percutaneous coronary intervention (PCI). After the intervention, he remained stable at the age of 95