Using a 3-vesel Virtual Histology (VH) intravascular ultrasound (IVUS), we evaluated the axial distribution of VH-IVUS-derived thin-cap fibroatheroma (VH-TCFA) between acute coronary syndrome (ACS) and stable angina pectoris (SAP). Pre-intervention 3-vessel VH-IVUS study was performed in 212 patients (105 ACS and 107 SAP). Using VH-IVUS, plaque was characterized as fibrotic, fibrofatty, dense calcium, and necrotic core. VH-TCFA was defined as necrotic core ���10% of plaque area without overlying fibrous tissue in a plaque burden ���40%. There were ruptured plaque in 55 lesions in ACS patients and 21 lesions in SAP patients. Most ruptured plaque were predominantly located from the ostium to 40mm (75%, 57/76); 17, 14, 19 and 7 in the first 10 mm, 11 to 20 mm, 21 to 30 mm and 31 to 40 mm segments. The axial distribution of ruptured plaque was similar between ACS and SAP; 27%, 20%, 22% and 9% vs. 10%, 14%, 33%, 10%. VH-TCFAs were observed in 262 lesions in ACS and 177 lesions in SAP. Most VH-TCFAs were predominantly located from the ostium to 40mm (83%, 365/439); 111 (25%), 110 (25%), 83 (19%) and 61 (14%) in the first 10 mm, 11 to 20 mm, 21 to 30 mm and 31 to 40 mm segments. The axial distribution of VH-TCFA was similar between ACS and SAP; 24%, 23%, 19% and 17% vs. 27%, 29%, 19%, 11%(Figure). Conclusion: Three-vessel VH-IVUS imaging showed that there was clear clustering phenomenon of VH-TCFA as well as ruptured plaque from the ostium to 40 mm of coronary artery.