50-year-old female without any risk factors, presented with chronic stable angina. Increased in intensity for a month. Echocardiogram showed ST/Tchanges. 2D Echocardiography was Normal. Treadmill Test -Strongly positive. Body Surface Area 1.45 square metres. Biochemistry - Normal
ICAD during CAG is rare (<0.2%). Deep catheter intubation, manipulation, non-coaxial positioning of tip, forceful contrast injections may cause it. Guiding with a larger curve 4 - 4.5 is advisable. Sinus injection is imperative to check retrograde dissections if any. Hydrophilic wire with ES is useful to track the true lumen. OTW system can be used as an additional support for the wire and also to administer contrast to confirm true lumen while advancing the wire. OTW system helps to exchange the wires. Stenting of entire length of the dissection is advisable to cover both exit points (proximal at sinus and distal in distal segment). Surgeon backup is required.