This is a case report of a 61-year-old female presenting with ongoing chest pain in the setting of an NSTEMI with lateral ST-T changes. On attempting to open the left circumflex (LCX), it resulted in a proximal LCX dissection. The patient remained stable with no further chest pain. She was treated with IV Eptifibatide for 48 hours and restudied in 72 hours. Repeat coronary angiography showed a marginally improved proximal dissection plane with a coronary AV fistula. She was managed conservatively and discharged with a non-invasive assessment in 8 weeks. The patient had a negative stress echocardiogram and was managed with maximal medical therapy. 1. Introduction Coronary AV fistulae are uncommon and bypass the myocardial capillary network and connect a coronary artery to another vessel or cardiac chamber. The primary etiology of coronary AV fistula is congenital and 0.25% is iatrogenic [1, 2]. Iatrogenic coronary AV fistulas are seen after acute myocardial infarction, aortic valve replacement, coronary angioplasty, coronary artery bypass graft surgery (CABG), endomyocardial biopsies, and thoracic trauma [3–11]. Given that iatrogenic coronary AV fistula is a rare complication, management guidelines are limited. However, there are several case reports discussing treatment options ranging from coil embolization, PTFE stent deployment and surgery [12–14]. 2. Case Report A 61-year-old female presents with a non-ST elevation myocardial infarction (NSTEMI) in the setting of previous percutaneous coronary intervention (PCI) to the right coronary artery (RCA) with a bare metal stent (BMS) in 2004 on a background of treated hypertension and hypercholesterolemia and smoking. Her regular medications were aspirin 81？mg OD, metoprolol 25？mg BID, ramipril 5？mg OD and atorvastatin 40？mg OD. Since admission, she had ongoing chest pain. Her ECG had lateral ST-T changes and the peak cTnI was 3.0？ng/mL. She was brought emergently to the cardiac catheterization laboratory. The procedure was completed via right transradial catheterization. Coronary angiography showed diffusely diseased left anterior descending coronary artery (LAD) with a 70% stenosis in the mid third with an occluded first obtuse marginal coronary artery (OM1) with TIMI 0 flow (Figure 1). The RCA was anterior in origin and nonselective coronary injection showed a patent stent (Figure 2). The OM1 was considered to be the culprit vessel and attempted to cross with Pilot 50 wire (Guidant Corp., Indianapolis, IN, USA). The wire crossed the proximal subsection of the left circumflex (LCX) with support (Abbott
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