An 84-year-old woman with hypertension, CKD, diabetes, and Cushing syndrome presented with altered consciousness and dyspnea. On arrival, her vital signs showed BP 112/78 mmHg, HR 125 bpm, and SpO₂ 66% on room air. Physical examination revealed bilateral rales, and distant heart sounds. Chest X-ray revealed bilateral pulmonary congestion, cephalization of vessels, and no consolidation, suggesting heart failure. 

Her ECG demonstrated ST depressions and T wave inversions in leads V2-V6, I, II, aVL, and aVF, indicating myocardial ischemia, potentially secondary to hypoxia and coronary artery disease. Laboratory results showed elevated Troponin I at 1.55 ng/mL and NT-proBNP at 7310 pg/mL, consistent with acute decompensated heart failure.

Coronary angiography showed significant stenosis:
Left main 50-60%,
LAD 80-90% (proximal to mid) with heavy calcification, diagonal branch 60-70%,
LCx 90-95% (ostium to proximal),
RCA 80-90% (proximal to mid), and PL branch functional CTO, collaterals from PDA, indicating multi-vessel disease.

Day 1:
IABP via R femoral artery, with 1 : 1 pumping.
7Fr SL 3.5 catheter via L femoral artery to LMCA. Runthrough wire to LAD distal, and Sion wire to D1.PTCA with NC Sapphire 3.5 × 20 mm at LAD. PTCA at LAD-D1 with Sapphire 2.0 × 20 mm, and at LCx with NC Sapphire 2.5 × 20 mm.IVUS for stent sizing. DES (Resolute Integrity) 2.5 ×30 mm stent at LAD mid. DES (Firehawk) 3.5 × 23 mm stent at LAD proximal.
Post-dilatation with NC Sapphire 3.5 × 15 mm.Coronary perforation (Ellis III) in LAD proximal: prolonged inflation with NC Sapphire 3.5 × 15 mm. Persistent perforation treated with covered stent (Abbot Graftmaster) 2.8 × 19 mm.
Wire entrapment from LCx to LAD-LM.Median sternotomy, CPB established. LV venting via RSPV & PA. Cardioplegia via root. Aortocoronary bypass to mid-LAD with vein graft. V-A ECMO post-CPB.Day 4:
7fr SL 3.5 catheter to LMCA. PTCA with Sapphire 2.5 × 20 mm and NC Conqueror 3.5 × 20 mm at LCx to LMCA. BMS (Waltz) 2.5 × 33 mm stent at LCx mid. BMS (Waltz) 3.5 × 18 mm stent at LCx to LMCA.
Post-dilatation with NC Conqueror 2.5 × 20 mm, 3.5 × 15 mm, 4.0 × 12 mm.
Final angiogram: TIMI III flow from LMCA to LCx.CPB from RA to aortic arch. Cardioplegia via root.
Aorta incised, wire cut near LMCA ostium.
Aortorrhaphy with 5-0 Prolene. CPB weaned, wound closed.

Guidewire entrapment during PCI is rare. In this case, the complication began with stent malapposition in the LAD, followed by post-dilatation that led to vessel perforation. During prolonged balloon inflation, the LCx wire was inadvertently pulled into the LAD, leading to guidewire entrapment when a covered stent was placed. Direct retrieval using a microcatheter was not possible, requiring surgery to cut the guidewire at the LM ostium, with the remaining LCx wire covered by a stent.This case highlights the need for guidewire position awareness during emergencies to prevent further complications.