In the late 1950s and early 1960s, more than 10,000 children in 46 countries were born with deformities, such as phocomelia and/or amelia, as a consequence of maternal thalidomide use. Application of thalidomide during weeks 3–8 of gestation causes multiple birth defects such as limb, ear, cardiac and gastric malformations [1, 2]. Patients with thalidomide-caused disabilities represent a small but complex patient population when it comes to diagnostic and therapeutic cardiac procedures. In this case, we detail our experience with a patient presenting severe phocomelia in combination with several other disorders including vascular abnormalities who suffered from coronary artery disease (CAD) with complex stenosis of the left anterior descending artery (LAD). A 52-year-old male patient presented in an outside hospital with symptoms of angina pectoris and shortness of breath. The patient’s history consisted of multiple birth defects due to maternal thalidomide use, hyperlipoproteinemia, adiposity, and smoking. ECG diagnostics and laboratory analysis revealed a ST-elevation myocardial infarction with a maximum creatine kinase level of 1,030 mg/dl. As such, the decision to perform emergency coronary angiography was made. After several efforts to place the cath-sheath transcutaneously, even surgical attempts to expose the femoral artery remained unsuccessful due to the underlying anatomic disorders. As the patient was in a stable condition, he was transferred to the intensive care unit for further monitoring and observation. To gain further insights in the coronary status as well as to detect the vascular access site options for coronary angiography or angioplasty, an ECG-triggered CT angiogram of the coronary arteries and of the existing vessels was performed. CT analysis identified a significant left anterior descendent artery (LAD) stenosis (culprit lesion) and a moderate stenosis of the left circumflex coronary artery. Analysis of the vascular status revealed no suitable access for catheterization. After interdisciplinary discussion, surgical revascularization via minimal invasive direct coronary artery bypass grafting (MIDCAB) was considered as the only viable treatment option in this particular case. After initiation of general anesthesia with a double lumen endotracheal tube, placement of the central venous and the arterial line for invasive blood pressure monitoring showed to be complicated and had to be performed under ultrasonographic guidance. An anterolateral thoracotomy was performed using the 5th intercostal space. After deflation of the lung, the left internal mammarian artery (LITA) was identified and dissected in the usual fashion. The vessel appeared to be small with a diameter of 1.5–2 mm, but showed no signs of affected or impaired condition. After heparinization and division of the mammarian artery, the pericardium was opened longitudinally. The LAD was identified in the epicardial fat and dissected. After chest tube placement and placement of a retractor stabilizer, temporary occlusion of the LAD with encircling 4-0 tourniquets sutures over silicone tubing was achieved. After incision of the target vessel and 2-mm shunt placement, the anastomosis between LITA and LAD was performed under direct vision using an 8/0 monofilament suture. Following completion of the anastomosis, the pedicle was fixed with two sutures to avoid torsion of the M. Scherner (&) M. Mihaijlova N. Madershahian T. Wahlers J. Wippermann Department of Cardiothoracic Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50925 Cologne, Germany e-mail: maximilian.scherner@uk-koeln.de