| Summary: | Introduction: A subset of anomalous coronary artery patients presenting as acute coronary syndrome are invariably hemodynamically unstable. Timely reperfusion with standard door to device time is real challenge in management of such patients. Presentation of case: Here, we reported a rare case of a 35-year-old male presenting with ST-elevation myocardial infarction with total thrombotic occlusion of proximal left descending artery (LAD) with anomalous right coronary artery (RCA) originating from mid LAD, distal to the total occlusion. Discussion: Co axial engagement of guiding catheter and delivery of hardware to target lesion are usual challenges during percutaneous intervention in anomalous coronary artery. However in our case localising the anomalous artery was real challenge. Conclusion: The traditional concept of” open the occluded artery and see,” can be a logical step in localizing the anomalous artery.
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