Summary A 69-year-old man with previous bypass surgery and multiple coronary stents presented with refractory angina. At angiography, the only suitable target was the left anterior descending artery (LAD), which had severe disease extending through an old stent into a large diagonal. Because of eccentric in-stent restenosis, it was only possible to access the diagonal after rotational atherectomy of the LAD through the previous stent. Subsequently separate angioplasty wires were passed into the LAD and diagonal. After sequential predilatation, T-stenting was performed using two drug-eluting stents, fi nalised with kissing infla tions and proximal optimisation using noncompliant balloons. He remains symptom-free at follow-up. taken, noting that both SVGs were occluded, with poor quality native vessels. However, the LIMA remained patent with good run-off. He underwent a viability magnetic resonance imaging (MRI) study, which demonstrated that the inferior wall was infarcted. At this point his left ventricular ejection fraction was 30%. He was therefore treated medically with escalating anti-anginal therapy. He remained symptom-free until early 2014 when he presented with an acute coronary syndrome (troponin T 420 ng/l, reference range <30 ng/l) and ECG changes suggesting ischaemia in the anterolateral wall. At this time our patient was receiving maximal tolerated medical therapy: aspirin 100 mg o.d., clopidogrel 75 mg o.d., carvedilol 25 mg b.d., ivabradine 5 mg b.d., ISDN MR 60 mg o.d., simvastatin 40 mg o.d., furosemide 40 mg o.d., gliclazide MR 60 mg o.d., metformin