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A 42-year-old male smoker, who hadn’t sought medical care before, presented to the emergency department with a two-day-history of persistent chest pain. Electrocardiogram (ECG) showed ST-elevation in precordial leads along with negative T-wave in inferior leads. Troponin-T level was high (1.92 ng/ml). He had tachycardia (130 beats/min) and low blood pressure (90/50 mmHg). Coronary angiography showed total occlusion of both the right coronary artery (RCA) and the left anterior descending artery (LAD) (figure 1); no signs of arterial dissection were found. An Intra-Aortic Balloon Pump (IABP) was inserted to stabilize the patient’s hemodynamic status and PCI was attempted but failed. Cardiac ultrasound revealed apical, septal and inferior left ventricular (LV) wall akinesia with a left ventricular ejection fraction (LVEF) of 30%, and no associated valvular disease. The patient was referred to us for surgical treatment. He was admitted to the operating room in a stable hemodynamic status under IABP. CABG was performed under cardio-pulmonary bypass and aortic cross-clamping. During the procedure, both mammary arteries were harvested (both were pedicled to their corresponding subclavian arteries). The RCA contained an organized clot adherent to the vascular wall; it was kept and the arteriotomy closed. The posterior descending artery (PDA) contained fresh clots. These were thrombectomized, then an end-to-side anastomosis with the RIMA was done. The RIMA, still pedicled to its origin, had enough length after adequate skeletonization. The LAD was found to be large (2.5 mm in diameter). The LAD-II arteriotomy uncovered a fresh clot that was thrombectomized. The proximal clot was inaccessible through this mid-segment arteriotomy; another arteriotomy was done at the LAD-I level (video 1), and the whole clot was removed. We anastomosed LIMA to LAD-I, side-to-side, then LIMA to LAD-II, end-to-side. Weaning of the cardio-pulmonary bypass, needed high doses of intravenous inotropes in addition to the active intra-aortic balloon pump (IABP). The patient was transferred to the cardiac surgery unit in a stable condition with adequate urine output. On the first post-operative day (POD), inotropes started progressive titration and the patient remained stable. The IABP was removed on POD4. The patient became fully autonomous on POD12 and was discharged home. One month later, echocardiography showed antero-apical left ventricular hypokinesia with an improvement of the LVEF reaching 55%. Haematological workup including factor V-Leiden, protein C, protein S, fibrinogen, anti-thrombin III, Factor Von-Willebrand, and a cardiovascular panel for mutations was completely normal. A follow-up coronary scan (figure 2) performed ten months after surgery showed complete occlusion of RCA, patent RIMA to PDA graft, patent native LAD bed, and patent LIMA to LAD graft.