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A patient with unstable angina and anterior ischemia on stress testing was referred for coronary angiography that should a significant mid LAD stenosis and an intermediate lesion in the first diagonal origin. The patient had a known CTO of the proximal circumflex and no significant disease in the RCA. Wiring the LAD was challenging and failed using an EBU 3.75 and EBU 3.5 guide catheter and a workhorse guidewire. Repeat attempts with an Ikari left guide catheter also failed and the patient started developing chest pain and ST segment depression, suggesting left main dissection. We were fortunately able to wire into the LAD with a Suoh 03 wire through the Ikari left guide catheter, followed by left main stenting and stabilization of the patient. The mid LAD lesion was successfully stented followed by kissing balloon inflation of the LAD/2nd diagonal bifurcation. The first diagonal lesion was not hemodynamically significant on physiologic assessment. The patient had an uneventful recovery with resolution of the chest pain.

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