Introduction: Acute subocclusion of left main stem is a major emergency, relatively rare in current practice. The rarity is that the extensive vascular myocardial territory of the left coronary artery (from 75% to 95%) makes the clinical presentation of patients with such a lesion usually catastrophic, with sudden death or severe cardiogenic shock. Current medical practice guidelines recommend emergency surgical myocardial revascula-rization (class I) as the first therapeutic option, percutaneous coronary intervention being a reasonable alter-native in patients with less complex anatomy (SYNTAX score< 33) and fewer comorbidities. The recent major development in interventional cardiology techniques and materials has made percutaneous approach a safe and effective option, with a long-term survival rate similar to surgical revascularization, although with a greater need for reintervention over time.

Case presentation: We present the case of a 62-year-old male patient, hypertensive, dyslipidemic, subopti-mally treated at home, who is urgently hospitalized for the clinical and paraclinical picture of anterior STEMI. Diagnostic coronary angiography reveals bivascular atherosclerotic coronary heart disease, with subocclu-sion in the distal segment of the left coronary trunk, involving the LAD and LCX ostia (Medina type 1-1-1 lesion). Given the impossibility of emergency surgery and the patient’s instability, we opt for immediate inter-ventional treatment, addressing the provisional sten-ting technique („as simple as possible“). Percutaneous coronary angioplasty is performed with the implanta-tion of a pharmacologically active stent in LMS-LAD „cross-over“ LCX, with optimal result. The subsequent evolution of the patient is slowly favorable, from cardiogenic shock with the need for positive inotropic support, acute renal injury and hepatic cytolysis in the context of severe LV dysfunction. The patient is discharged 12 days post-infarction, with improved systolic function, without signs or symptoms of heart failure, nitrogen retention or hepatic cytolysis.

Particularity: Rarely encountered severe atherosclero-tic coronary heart disease, with subocclusion in the left coronary trunk involving LAD and LCX ostia (Medina type 1-1-1) Complex interventional management with coronary angioplasty and implantation of phar-macologically active stent in LMS-LAD „cross-over“ LCX. Post-procedural cardiogenic shock with acute kidney injury and hepatic cytolysis. Spectacular evolution with the improvement of LV systolic function and remission of hepatic cytolysis syndrome and nitro-gen retention.