A 62-year-old Malay male, active smoker, diabetic mellitus, dyslipidemia, ischemic heart disease presented with unstable angina. Previous month Myocardial perfusion scan showed infarction involving the RCA and LCx territories. He was scheduled for emergency coronary angiography. Clinically, the patient had resolved chest pain, haemodynamically stable. Cardiovascular examination revealed a dual rhythm with no murmurs, and pulmonary examination showed equal.

• ECG: Sinus rhythm, heart rate 75 bpm • Echocardiogram: Preserved left ventricular function (EF 55%) with mild regional wall motion abnormalities in RCA and LCx territories. • MPS: Infarcted RCA and LCx territories, viable anterior wall.

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The procedure was performed via a 6 French femoral approach. The LAD was wired using a BMW guidewire and pre-dilated sequentially with non-compliant balloons sized 2.5 × 15 mm and 3.0 × 15 mm, achieving satisfactory lumen expansion. Considering the diffuse nature of the lesion, a DCB-only strategy was selected to avoid multiple overlapping stents. DCB angioplasty was carried out, sized 2.5 × 30 mm and 3.0 × 25 mm, each inflated for 60 seconds. The final angiogram revealed mild vessel recoil and a non–flow-limiting dissection with TIMI 3 flow. To optimize the result, the operator attempted re-wiring for bailout stenting; however, the guidewire inadvertently entered a false lumen. Despite this, pre-dilatation was performed followed by deployment of a 2.5 × 26 mm Onyx drug-eluting stent from the mid to distal LAD. Subsequently, the vessel flow deteriorated to TIMI 0. Intravascular ultrasound confirmed subintimal stent placement with a long false lumen extending from the mid LAD before the septal branch. Multiple attempts to re-enter the true lumen, both proximally and distally, were unsuccessful. The patient developed chest discomfort, which was partially relieved with morphine. In view of persistent LAD occlusion, intra-aortic balloon pump (IABP) support was initiated for hemodynamic stabilization, and the patient was referred for urgent coronary artery bypass grafting (CABG).



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In patients undergoing DCB-only angioplasty, careful post-procedure assessment is essential. Non–flow-limiting dissections can be accepted when flow is preserved, and patient asymptomatic , as premature re-intervention may precipitate catastrophic complications. In cases requiring additional wiring or stenting, intravascular imaging should be used to confirm true lumen position and guide intervention safely. Once subintimal stenting occurs, percutaneous re-entry is technically demanding and often unsuccessful; thus, early recognition and timely surgical referral offer the best chance of myocardial salvage.