Initial visualization of only the left circumflex coronary artery during coronary an-giography in a 71-year-old patient with prior stenting of the left anterior descending (LAD) coronary artery would have led to an erroneous conclusion of a thrombosed stent and occluded coronary artery with its consequent management problems, before it was disclosed that the LAD originated from a separate ostium. A 71-year-old gentleman with a history of coronary artery disease was admitted for scheduled

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... y angiography due to stable angina class II symptoms and positive thallium scintigraphy. The patient had been submitted to percutaneous coronary intervention 3 years earlier with stenting of the left anterior descending (LAD) coronary artery due to unstable angina and critical coronary stenosis at that time. No recorded imaging was available for review from this previous intervention. With the first injections into the left coronary artery, only the left circumflex coronary artery was visualized, while it was apparent that the LAD was missing at its origin and only the contour of a stent (arrows) could be discerned along the imaginary course of its proximal segment in both left anterior oblique projections with cranial (Figure 1, panel A) and caudal (panel B) angulations. The right coronary artery was patent (not shown). An initially presumed occlusion of the LAD did not entirely fit the clinical scenario of this patient particularly in the absence of collaterals to the LAD noted during repeated contrast injections into the right coronary artery and delayed cine-angiographic views obtained for this purpose. Thus, the angiographer made further attempts to localize the missing LAD and he was finally successful to engage a separate LAD ostium at the left sinus of Valsalva in juxtaposition to the ostium of the left circumflex coronary artery, revealing a patent LAD and non-occluded stent with no significant restenosis (short arrows, panels C and D). ••• Congenital anomalies of the coronary arteries account for ~1% of all coronary angiographies being performed, and among them an absent left main coronary artery is detected in ~0.4%. 1.2 In the majority of such cases, two separate adjacent coronary ostia are identified in the left aortic sinus of Valsalva, whereby the LAD and the left circumflex coronary arteries have their separate origins. This was the situation in the present case, which was finally correctly identified and serious consequences of a misinterpreted coronary angiogram were averted. In this particular case of a previously stented LAD, the obvious but erroneous conclusion would have been that of a ImAgeS In medICIne Key WoRdS: coronary anomalies; coronary artery disease; coronary stenting; coronary stent thrombosis; absent left main coronary artery; separate ostia of left coronary arteries AbbreviAtions CT = computed tomography CTA = computed tomography coronary angiography LAD = left anterior descending (coronary artery) LAO = left anterior oblique (angiographic view) Conflict of interest: None declared