A 70 years male knowncase of hypertension, hyperlipidemia & case IHD, PCI pLAD & RCA 2019, recentNSTEMI coronary angiogram showed distal LMS stenosis, ostial LCX and LAD severedisease & ISR LAD & RCA. Counselled for CABG, but not keen, referred tous for high risk multivessel angioplasty angioplasty. Echo showed EF 41%. 
LAD LMS angio vedio.avi
RCA angio Vedio.avi

tortious Femoral artery, needs stiff wire to straighten it and then advanced long arrow sheath 
RFA ved.avi
RFA taflon wire canot cross.avi
Arrow sheath ved.avi

Tortous RCA, difficult witing, managed to pass prediltationballoon  after straightening  the artery with guide plus and grand slam wire.Predilated with Minitrek 2.0x 10, IVUS showed Severe In-Stent Restenosis,old stent is under sized,2.5 stent. Vessel size 3.0-3.5 distally, heavy plaqueburden.Predilated with Wedge NC 2.5 x 10, & NC Emerge 3.0 x 8mm at ostium Stented in stent withSynergy 3.0 x 48mmPostdilated with NC Emerge 3.5 x 12mm & 4.0/12 proximally 
with baloob anchor manage to wire vedi.avi
stenting RCA vedio.avi

DKCrushstenting  LMS/LAD/LCXRFA7F sheath changed to long arrow sheath 7F IVUSshowed Left Anterior Descending - Severe In-Stent Restenosis, vessel size 3.0 -35 proximal LAD. LCX - Diffuse severe disease from ostium to distal vessel size3.0. Left Main Stem - Vesselsize 5.0, moderate disease, distal segment.Predilatedwith LCX to LMS and LAD  with Scoreflex2.5 x 15mm then Predilated with EmergeNC 3.0 x 15mm. Stented distal – pLCX withCRE 8 3.0 x 46. Stented  pLCX to LMS with CRE 8 3.0 x 12mm at proximal segment with NC 3.5 x 15mm crushedLeft Circumflex stent, Rewired Left Circumflex, open stent strut with Sapphire2.0 x 15mm, POT Left Main Stem withNC 4.5 x 8mm, 1st Kissing LAD 3.0 x15mm and LCX 3.0 x 15mm.StentedLAD to LMS with CRE 8 3.5 x 20mm, 2nd Kissing - LAD 3.6 x 15mm and Left Circumflex 3.0 x15mm, POT Left Main Stem withNC Emerge 4.5 x 8.UpsizedLAD stent with 4.5 x 8mm NC,Postdilated Left Main Stem with Emerge 5.0 x 8mm, IVUS post All stent well opposed, no dissection   
stenting pLCX vedio.avi
stenting LAD LMS vedio.avi
final lms.avi

Coronary artery tortuosity is a common angiographic finding and has been associated with difficulty in passing wire, balloon and stents and also with  adverse events after PCIThe use of adjuvant stool such as super stiff wire, arrow sheath to over come femoral tortuosity and guideliner and grand Slam wire for coronary .The usefulness of intravascular imaging to understand ISR .