Acute left main coronary artery occlusion--a case report and review of the literature

Acute left main coronary artery (LMCA) occlusion is rare and typically fatal. According to the recent literature, only three cases have been reported surviving emergent coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) caused by total LMCA occlusion. We report the case of a 52-year-old man presenting with total occlusion of the LMCA associated with acute anterolateral myocardial infarction and cardiogenic shock. The patient's dominant right coronary artery did not supply the collaterals to the left coronary system. After ineffective thrombolysis the patient underwent successful emergent CABG for the management of uncontrollable cardiogenic shock. Emergent CABG, though controversial, appears to be a feasible approach for patients with AMI in life-threatening situations, when other attempts at reperfusion have been unsuccessful.     

Stenting of the left main coronary artery. Local experience in Liège

We examined the immediate and long-term outcome after stenting of the left main coronary artery (LMCA) in 41 consecutive patients who had been considered unsuitable for coronary artery bypass graft surgery (CABG). The procedure was elective in thirty-two patients (78%) with a protected LMCA in 24 patients and non-protected LMCA in 8 patients; the procedure was acute in the setting of myocardial infarction or complication of a diagnostic angiography in 9 patients (22%). The mean follow-up duration was 19 +/- 13 months. There were 5 in-hospital and 3 late deaths; repeat angioplasty was performed in 5 cases, but only one for LMCA restenosis. Results varied considerably depending on the clinical presentation. For acute patients, technical success was achieved in 89%, survival at hospital discharge was 44% and there was no cardiac event at the late follow-up. For elective patients, technical success was achieved in 100%, survival at hospital discharge was 96% and 90% at follow-up. The results of our study suggest that when patients have surgical risks, elective LMCA stenting either protected or unprotected may be undertaken with a high procedural success rate and a favourable clinical late follow-up.     

Acute reocclusion during percutaneous transluminal coronary angioplasty: immediate and long-term outcome

Acute total occlusion of a coronary artery during percutaneous transluminal coronary angioplasty (PTCA) has previously resulted in emergency surgical intervention (CABG). We retrospectively surveyed 211 elective procedures and 65 procedures for acute myocardial infarction (AMI). There were 42 patients (pts) [29 elective (14%) and 13 AMI (20%)] in whom total occlusion occurred after initial dilation had been achieved. In 30 of 42 pts reangioplasty successfully reperfused the vessel. Ten patients (24%) required CABG and two (5%) were treated medically for AMI. Death occurred in 2 pts due to irreversible cardiogenic shock despite successful angioplasty. After 6 months follow-up 22 pts remained asymptomatic. It is concluded that aggressive redilation of total occlusions which develop during PTCA will frequently result in a successful angioplasty with a long-term restenosis rate comparable to uncomplicated angioplasty.     

Elective coronary stent implantation in cardiogenic shock complicating acute myocardial infarction: in-hospital and six-month clinical and angiographic results.

Effective treatment of patients with acute myocardial infarction and cardiogenic shock depends on restoring persistent patency of the infarct-related artery. Coronary stenting, reducing abrupt or delayed closure related to dissection and suboptimal result, may improve PTCA results in cardiogenic shock. Eighteen patients (14 males and 4 females, mean age 59 +/- 7 years), referred to catheterization laboratory for acute myocardial infarction and shock, had elective stent implantation during 14 primary and 4 rescue PTCA. Time delay between shock onset and PTCA was 4.1 +/- 3 hr (range, 30 min to 12 hr). The IRA was LAD in seven patients (38%), LCx in two (11%), and RCA in eight (45%). One patient (5.%) had distal LMCA occlusion. Stent deployment was successful in 100% of patients and resulted in TIMI 3 flow in 13 (72%) patients. In 13 (72%) cases, cardiogenic shock gradually resolved and the patients were discharged alive. Five patients (28%) died because of irreversible hemodynamic deterioration without evidence of reinfarction. At 6-month follow-up, all the discharged patients were alive and no patient had reinfarction or recurrent angina. Heart transplant was required in one patient 5 months after stenting because of refractory congestive heart failure. Angiography demonstrated patency of all the coronary arteries treated, with TIMI 3 flow in all patients. Stent restenosis rate was 30%, and target lesion revascularization with CABG or re-PTCA was not required in any case. LV function improved from 39% +/- 15% to 51% +/- 15% (P < 0.01). Elective coronary stenting is an effective treatment for acute myocardial infarction complicated by cardiogenic shock and may improve acute and long-term survival.     

Effect of primary angioplasty on total or subtotal left main occlusion: analysis of incidence, clinical features, outcomes, and prognostic determinants

BACKGROUND: Although acute left main coronary artery (LMCA) occlusion is a rare clinical entity, it carries a very high mortality rate. The purposes of this study were to evaluate the effect of primary angioplasty for a severely obstructed or totally occluded LMCA, and to determine the incidence, clinical features, outcome, and prognostic determinants in this clinical setting. MATERIALS AND METHODS: Between May 1993 and July 2000, a total of 740 patients with acute myocardial infarction underwent primary angioplasty in our hospital. Eighteen of 740 patients (2.4%) with a severely obstructed or totally occluded LMCA constituted the population of this study. RESULTS: Seventeen of 18 patients (94.4%) experienced pulmonary edema (including 14 patients in cardiogenic shock). Six patients (33.3%) sustained sudden death due to malignant ventricular tachyarrhythmias. Coronary angiography showed that there were variable grade flow of intercoronary collaterals in 12 patients (66.7%), a totally occluded LMCA in 8 patients (44.4%), an incompletely occluded LMCA in 10 patients (55.6%), and a dominant right coronary artery (RCA) in 16 patients (88.9%). Primary angioplasty of the LMCA was performed with a 72.2% procedural success rate. Four patients (22.2%) received coronary artery bypass surgery after angioplasty. Six patients (33.3%) died in the hospital. Two patients died after discharge. Ten of 18 patients (55.6%) survived in long-term follow-up (mean +/- SD, 44 +/- 14 months). Those patients who survived to be discharged had significantly higher combined coexisting incidence of intercoronary collaterals, dominant RCA, and incompletely occluded LMCA (100% vs 0.0%, p = 0.0006) than those patients who died in the hospital. CONCLUSIONS: Acute obstructive LMCA disease generally presented as pulmonary edema, cardiogenic shock, or sudden death. Only those who had combined coexistence of intercoronary collaterals, a dominant RCA, and an incompletely occluded LMCA could survive to be discharged. Our experience suggests that primary LMCA angioplasty is a feasible and effective procedure, and it may save lives in this clinical setting.     

Primary angioplasty of unprotected left main coronary artery for acute anterolateral myocardial infarction

BACKGROUND: Mortality of acute unprotected left main coronary artery (LMCA) occlusion is very high. The objectives of this analysis were to determine the effect of primary angioplasty and the impact of cardiogenic shock on unprotected LMCA occlusion-induced acute anterolateral myocardial infarction (AAMI). METHODS: Of 1,736 consecutive patients with acute myocardial infarction (AMI), 38 (2.2%) had LMCA occlusion-induced AAMI with Thrombolysis in Myocardial Infarction (TIMI) flow less than or equal to 2. All were given primary angioplasty. RESULTS: Of these 38 patients, 17 (45%) were discharged, and 21 (55%) died in-hospital. Cardiogenic shock was overt in 28 patients; 47.1% of the survival group and 95.2% of the mortality group (p=0.0008). On arrival, the survival-group had higher pH (7.40+/-0.10 vs. 7.30+/-0.14; p=0.013) and base excess (-4.5+/-3.9 vs. -10.4+/-6.0 mEq/L; p=0.0013). In the survival group reperfusion was successful in 100% of patients, as opposed to 57.1% in the mortality group (p=0.0020), and the incident of stenting was not different between the two groups (64.7% vs. 71.4%, p=0.66). Shock patients had lower successful angioplasty rate (67.9% vs. 100%, p=0.040), higher in-hospital mortality (71.4% vs. 10.0%, p=0.0008), and higher 1-year mortality rates (p=0.0064), than stable patients. All shock patients with failed angioplasty died, but the mortality rate was 57.9% (p=0.021) when angioplasty was successful. CONCLUSIONS: Patients presenting with AAMI, LMCA occlusion, and cardiogenic shock have poor survival regardless of primary angioplasty in conjunction with coronary stents. Nevertheless, primary angioplasty is a feasible and effective procedure, and it may save lives in this clinical setting.     

Primary percutaneous coronary intervention for the treatment of a patient with cardiogenic shock due to acute total occlusion of unprotected left main coronary artery without supportive collateral flow

Total occlusion of unprotected left main coronary artery (LMCA) is rarely encountered in clinical practice and the incidence cannot be determined precisely, since most of the patients die before hospital admission. Malignant arrhythmia, cardiogenic shock or sudden death due to pump failure develops in most of these patients. The cases complicated by cardiogenic shock have bad prognosis in both the short and long term, despite the advancements in reperfusion treatments. Successful treatment of sudden total occlusion of unprotected LMCA has been rarely reported. Over the last decade, many cases and comparisons in patients with LMCA lesions were reported on percutaneous interventions for unprotected LMCA using different stent and stenting procedures or in comparison to coronary bypass surgery. On the other hand, these patients either had stable coronary artery disease or a partially occluded LMCA in the setting of acute coronary syndromes with well supporting collateral flow. In our case, a 50 year-old male patient with cardiogenic shock and extensive anterior ST-elevation myocardial infarction due to acute total occlusion of unprotected LMCA, who was not receiving collateral flow from the right coronary system, was treated successfully through primary percutaneous coronary angioplasty, was presented. In our case, there was an totally occluded unprotected LMCA without any supportive coronary flow to left system. In this regard, our case is unique in literature.     

Emergency coronary stenting of unprotected critical left main coronary artery stenosis in acute myocardial infarction and cardiogenic shock

In the setting of acute myocardial infarction (MI) and cardiogenic shock in patients with significant unprotected left main coronary artery (LMCA) disease, treatment options are limited. In this report of a patient presenting in cardiogenic shock secondary to acute MI with critical LMCA stenosis, percutaneous coronary intervention with intra-aortic balloon pump support proved life saving.     

Percutaneous transluminal coronary angioplasty in patients with cardiogenic shock.

In cardiogenic shock complicating acute myocardial infarction, percutaneous transluminal coronary angioplasty has been reported to significantly improve the modest survival benefits afforded by emergency surgical revascularization and thrombolytic therapy. The records of all patients who underwent angioplasty for acute myocardial infarction complicated by cardiogenic shock were retrospectively reviewed to determine whether coronary angioplasty improves survival. Of the 45 patients, 28 (group 1, 62%) had successful dilation of the infarct-related artery and 17 (group 2, 38%) had unsuccessful angioplasty. The groups were similar in extent of coronary artery disease, infarct location, incidence of multivessel disease and hemodynamic variables. The overall hospital survival rate was 56% (71% in group 1 and 29% in group 2). Group 1 patients had more left main coronary artery disease, and group 2 patients were older and had a higher incidence of prior myocardial infarction. Multivariate analysis showed that the survival advantage in patients with successful angioplasty was statistically significant (p = 0.014) when these factors were taken into account. At a mean follow-up interval of 2.3 years (range 1 month to 5.6 years), there were five deaths (four cardiac and one noncardiac), for a 2.3-year survival rate of 80% in patients surviving to hospital discharge. During the follow-up period, 36% of hospital survivors had repeat hospitalization for cardiac evaluation, 8% had myocardial infarction, 8% had coronary artery bypass surgery and 24% had angina.     

überlebter akuter Myokardinfarkt mit Hauptstammverschluss der linken Koronararterie

Survival of acute total occlusion of the left main coronary artery (LMCA) is rare. The majority of these patients die suddenly due to extensive acute myocardial infarction with cardiogenic shock and arrhythmias. Early recognition of symptoms and accurate detection of myocardial infarction, prompt percutaneous coronary intervention, shock treatment with intra-aortic balloon pump and early emergency coronary artery bypass grafting led to survival of a young male patient with acute occlusion of the left main artery in our case.     

Primary stenting of an unprotected left main coronary artery total occlusion in a patient with acute myocardial infraction and cardiogenic shock

Acute total occlusion of the left main coronary artery (LMCA) is a rare angiographic finding with very poor prognosis. We report a case of a 39-year-old man who presented with pulmonary edema and cardiogenic shock due to an acute anterior myocardial infarction. Coronary angiography, which was performed under the support of an intra-aortic balloon pump, revealed total occlusion of the LMCA. Prompt and successful percutaneous transluminal coronary angioplasty with sirolimus-stent deployment in the LMCA allowed for an uneventful recovery and discharge of the patient.     

Successful treatment in a case of acute aortic dissection complicated with acute myocardial infarction due to occlusion of the left main coronary artery

The patient was a 67-year-old man who was diagnosed with acute myocardial infarction based upon the general symptoms and electrocardiographic findings. Emergent coronary angiography showed a 99% stenosis of the left main coronary artery (LMCA). After the 4.0 mm stent was implanted, he recovered from cardiogenic shock. An acute, Stanford type A aortic dissection was diagnosed by computerized tomography performed after the angioplasty. Transesophageal echocardiography showed that a retrograde dissection of the aorta was compressing the left main coronary ostium. Successful implantation of the stent at the LMCA contributed to saving the patient s life.     

Initial and long-term results of angioplasty in unprotected left main coronary artery

Angioplasty of the unprotected left main coronary artery (LMCA) has been controversial. Although recent single-center studies suggest that new devices may change the situation, many questions and problems remain. Therefore, the results of unprotected left main coronary angioplasty of 175 procedures in 107 patients were analyzed to evaluate its feasibility and effectiveness. The treatment of the initial 107 cases included balloon angioplasty (39 cases, 36%), directional coronary atherectomy (53 cases, 50%), and stents (15 cases, 14%). They were divided into 3 major subgroups: (1) acute group (n = 14), in which LMCA angioplasty was performed in patients with acute myocardial infarction; (2) emergency group (n = 10); and (3) elective group (n = 83). In-hospital mortality was higher in the acute (35.7%) and emergency (40.0%) groups than in the elective group (3.6%; p <0.0001). Angiographic follow-up was routinely performed and the restenosis rate including in-hospital restenosis was 70% in the acute group, 37.5% in the emergency group, and 40% in the elective group (p = NS). The mean clinical follow-up period was 2.9 years, and the estimated 5-year survival rates of the acute and emergency groups were 50% and 48.2%, respectively. However the 5-year survival rate of the elective group was higher than that seen in the acute or emergency group (77.5%; p <0.05). Repeat LMCA angioplasty was performed in 37 of 68 patients with 8.8% mortality (38.5% of acute and emergency cases and 1.8% of elective cases). The results indicated that elective unprotected LMCA angioplasty is relatively feasible and effective under scheduled angiographic follow-up.     

Coronary angioplasty for medically refractory unstable angina within 30 days of acute myocardial infarction

Percutaneous transluminal coronary angioplasty (PTCA) has been used with good results in selected patients with unstable angina. The population with recent (less than or equal to 30 days) infarction and unstable angina is a subject of controversy. This report reviews the results of angioplasty of 84 vessels in 66 patients with medically refractory unstable angina who had documented myocardial infarction within 30 days of the procedure. Of these 66 patients, 54 had rest angina. Of the 66 patients with angioplasties, 58 patients (88%) had successful procedures. Two patients had technically unsuccessful results in the only vessel attempted; one went to elective surgery and recovered uneventfully and the other patient was in cardiogenic shock at the time of the procedure and died 12 hours later. There were three acute occlusions of infarct-related arteries that were managed medically. There were two (3%) emergency coronary artery bypass graft (CABG) procedures. There were two (3%) deaths during the index hospitalization. Of the 58 of 66 patients with technically successful angioplasty, all 58 had no more rest angina, and 46 had a satisfactory predischarge exercise test. All 46 were without angina at exercise. In follow-up ranging from 4 months to 36 months (14 months mean), there have been six cases of restenosis with recurrence of angina treated successfully with repeat angioplasty. There have been five late bypass surgeries. There have been three late deaths. These data, generated by a single operator in a Veterans Administration (VA) center, support the use of angioplasty in patients with unstable angina and recent myocardial infarction. The data suggest that a VA prospective randomized trial of PTCA versus CABG for post-infarction angina may be feasible.     

Primary angioplasty for acute myocardial infarction complicated by cardiogenic shock on admission.

AIM: To evaluate primary angioplasty results for the treatment of acute myocardial infarction complicated by cardiogenic shock on admission. POPULATION AND METHODS: Retrospective analysis of 11 consecutive patients with acute myocardial infarction complicated by cardiogenic shock (defined as systolic blood pressure below 80 mmHg and signs of hypoperfusion, despite volume expanders and/or vasopressors infusion) treated with primary angioplasty. Clinical characteristics, angiographic data, hospital outcome and follow-up were analysed. RESULTS: There were ten males (90.9%) with a mean age of 66 years. Eight patients had anterior wall myocardial infarction and three patients had inferior wall myocardial infarction, two of which with extension to the right ventricle. The mean time between symptom onset and angioplasty was 3.5 hours. Three patients had left main coronary artery occlusion; three patients had single vessel disease and five patients had multivessel disease. The angiographic success rate (open infarct-related artery and TIMI III flow) was 90.9% (ten patients). Stent implantation was performed in five patients. Abciximab was given in five patients. In-hospital mortality rate was 36.4% (four patients). The surviving patients had a mean ejection fraction of 43.1% on discharge. In a mean follow-up of 16.2 months, one patient had coronary artery bypass graft and one had stroke. CONCLUSION: Based on published data, our experience with this short series of cases shows that primary angiography should be regarded as a positive option for the treatment of acute myocardial infarction complicated by cardiogenic shock.     

Immediate and long-term outcomes of stent implantation for unprotected left main coronary artery disease

Left main coronary artery (LMCA) disease is now uniformly treated with coronary artery bypass grafting (CABG). However, some patients with LMCA disease do not receive CABG because of high operative risks. The advent of stent implantation has permitted a non-operative improvement in myocardial blood flow in many patients with single- and multi-vessel coronary artery disease. However, the outcomes of stent implantation for unprotected LMCA disease are still unclear. Stent implantation was performed for unprotected LMCA disease in 13 patients; eight patients had high operative risk and five patients had refused CABG. The primary success rate was 100% (13/13 patients). One patient (8%) developed a non-Q-wave myocardial infarction after LMCA stenting. Repeat angiography was obtained in five patients (38%) with recurrent angina, and three patients (23%) received repeated percutaneous transluminal coronary angioplasty (PTCA) for LMCA restenosis. In the follow-up period of 18±3 months, 12 patients (92%) remained in satisfactory condition with no further need for surgical intervention. One patient (8%) ultimately required CABG, and she died after CABG at 3 months after LMCA stenting. In conclusion, although CABG remains the standard treatment for LMCA disease, the present study demonstrates that stent implantation is a safe and clinically beneficial revascularization procedure for unprotected LMCA disease in patients who have high operative risk as well as those who refuse CABG.     

Identification of acute myocardial infarction patients suitable for early hospital discharge after aggressive interventional therapy. Results from the Thrombolysis and Angioplasty in Acute Myocardial Infarction Registry

BACKGROUND. Very early (day 4) hospital discharge has recently been proposed for selected patients with acute myocardial infarction (MI). The purpose of this study was to determine the most useful factors for identifying acute MI patients treated with aggressive interventional therapy who could be safely discharged on day 4. METHODS AND RESULTS. We studied 708 patients enrolled in the Thrombolysis and Angioplasty in Acute Myocardial Infarction trials I-III. Patients dying in the first 3 days and those with early (days 1-3) emergency coronary artery bypass graft surgery (CABG), late elective CABG (greater than or equal to day 4), or urgent/emergency CABG resulting from a late elective coronary angioplasty were excluded. The remaining 580 patients were randomly divided into a training sample (group 1) that was used to build a logistic regression model for predicting the absence of a late major complication and a test sample (group 2) that was used to validate this model. For this study, patients were considered appropriate for day 4 hospital discharge if they did not experience any of the following for 30 days after MI: death, reinfarction, cardiogenic shock, pulmonary edema, sustained hypotension, sustained ventricular tachycardia, high-grade atrioventricular block, acute ventricular septal defect, and recurrent ischemia necessitating urgent CABG. In group 1, four variables were independent predictors of freedom from late major complications: absence of early sustained ventricular tachycardia or ventricular fibrillation, absence of early sustained hypotension or cardiogenic shock, fewer coronary arteries with significant (greater than or equal to 75%) stenosis, and a higher left ventricular ejection fraction. In group 2, 23% of patients had a logistic model prediction of a 3% or less chance of a late complication. These patients had no deaths or reinfarctions by day 30 and a 3% late major complication rate. CONCLUSIONS. The results of early cardiac catheterization and the absence of selected early (days 1-3) major complications do allow identification of a low risk subgroup of acute MI patients that may be suitable for very early discharge.     

Thrombolysis in acute myocardial infarction complicated by cardiogenic shock

The adverse impact of the development of cardiogenic shock in the setting of acute myocardial infarction was first described by Killip and Kimball in 1967. While the inhospital mortality rate in patients with myocardial infarction and no evidence of heart failure was only 6%, the mortality rate in those patients who developed cardiogenic shock was 81%. Despite advances in cardiovascular care and therapy since that initial report, including universal institution of cardiac care units, advances in hemodynamic monitoring, new inotropic and vasodilating agents, and even increasing utilization of thrornbolytic therapy, the mortality from acute myocardial infarction, when complicated by cardiogenic shock, remains disturbingly high, and cardiogenic shock remains the leading cause of death of hospitalized patients following acute myocardial infarction.The grave prognosis associated with this condition has resulted in increased interest in potential therapeutic interventions, particularly in the area of reperfusion therapy. Several studies suggest that, in contrast to the beneficial effects of thrombolytic therapy in most patient populations suffering acute myocardial infarction, mortality rates are not decreased in those patients with cardiogenic shock at the time of lytic administration. Thrombolytic administration does, however, appear to lead to a modest reduction in the percent of patients with myocardial infarction who will subsequently develop cardiogenic shock during hospitalization.Reperfusion rates with lytic therapy in patients with cardiogenic shock are disappointingly low, in the range of 42–48%, significantly lower than those achieved in patients without cardiogenic shock. These low perfusion rates may, in part, be explained by decreased coronary blood flow and perfusion pressure in patients with left ventricular pump failure.Although promising as adjunctive therapy, it is unclear whether institution of balloon counterpulsation has any long-term benefit in patients with cardiogenic shock treated with thrombolytic therapy. Whether other or additional interventions, such as coronary angioplasty and coronary artery bypass graft (CABG), decrease mortality rates in patients with cardiogenic shock remains to be determined.     

Timing and mechanism of in-hospital and late death after primary coronary angioplasty during acute myocardial infarction

The effect of early myocardial reperfusion on patterns of death after acute myocardial infarction (AMI) is unknown. Thus, the mechanism and timing of in-hospital and late deaths among a group of 614 patients treated with coronary angioplasty without antecedent thrombolytic therapy for AMI were determined. Death occurred in 49 patients (8%) before hospital discharge. Four patients died in the catheterization laboratory. Death was due to cardiogenic shock in 22 patients, acute vessel reclosure in 5 patients, was sudden in 8 patients and followed elective coronary artery bypass surgery in 8 patients. Cardiac rupture was observed in only 2 patients after failed infarct angioplasty, and did not occur among the 574 patients with successful infarct reperfusion. Intracranial hemorrhage did not occur. Multivariate predictors of in-hospital death included failed infarct angioplasty, cardiogenic shock, 3-vessel coronary artery disease and age greater than or equal to 70 years. During a follow-up period of 32 +/- 21 months (range 1 to 87), 55 patients died. The cause of death was cardiac in 36 patients, including an arrhythmic death in 23 patients and was due to circulatory failure in 13 others. One patient died of reinfarction due to late reclosure of the infarct artery. Actuarial survival curves demonstrated overall survival after hospital discharge of 95 and 87% at 1 and 4 years, respectively. Freedom from cardiac death at 1 and 4 years was 96 and 92%. Multivariate predictors of late death included 3-vessel disease, a baseline ejection fraction of less than or equal to 40%, age greater than 70 years and female gender.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ostial left main coronary artery chronic total occlusion presenting as chronic stable angina

Significant left main coronary artery (LMCA) disease is found in 5–6% of all patients undergoing coronary angiography. It usually presents as acute coronary syndrome and is commonly associated with multi-vessel coronary artery disease (CAD). Complete occlusion of LMCA is a much rarer finding, since these patients usually present as unstable angina, myocardial infarction and cardiogenic shock. We report a case of a young female, who presented with chronic stable angina and had an isolated chronic total occlusion (CTO) of LMCA with no lesions in the other coronary arteries. Aortogram failed to demonstrate the stump of occluded LMCA and demonstrated the filling of the left coronary system from the right coronary artery. Apart from dyslipidemia, she had no other risk factors for CAD. She was extensively evaluated for non-atherosclerotic causes of LMCA CTO including vasculitis. She underwent coronary artery bypass graft successfully without any peri-procedural complications.