A patient presented with inferior STEMI. He had occlusion of the mid right coronary artery that was successfully recanalized. He also had a severe lesion in a highly tortuous circumflex coronary artery. The following day he was referred for staged revascularization of the proximal circumflex lesion. Wiring was very challenging due to tortuosity. A Sion black and Suoh 03 guidewire failed to advance into the circumflex and kept prolapsing into the LAD, even after using a Caravel microcatheter. Using a Venture microcatheter a Sion blue guidewire was advanced into the circumflex. Balloon and stent delivery was also challenging. During stent delivery attempts the patient became hypotensive and developed ST segment elevation due to left main dissection. A 3.0x23 mm DES was deployed from the left main into the circumflex restoring antegrade flow with resolution of the ST segment elevation and hypotension. A nice final result was achieved after optimization using IVUS. The patient had an uneventful recovery.

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