The case of a 52-year-old man with an anomalous origin of the left coronary artery from the right sinus of valsalva coursing between the aorta and pulmonary trunk is reported with an acute myocardial ischemia. He had an additional high-grade main-stem stenosis in the course behind the pulmonary artery. The anatomical variants, clinical significance, and cause of ischemia are discussed. Also, technical considerations in both diagnosis and management are given.
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