 Male  patient, 35 years old , Smoker , Diabetic ,Dyslipidemic , History of Multiple sclerosis since 2010 receiving Steroids .  Presented with Typical anginal pain recurrent for 3 days and maximum 10 hrs before presentation to ED. Generally : No signs or symptoms of heart failure  Local ex: Audible HS with no added murmurs  Bl pr : 116 / 69 , HR 83 b/m , Temp: 37.2 , RR : 19 

 RBS : 326   ECG shows : Sinus Rhythm with ST depression in all leads and elevation AVR wave  Echo shows : ischemic heart disease with EF 48 % , segmental wall motion in the form of mid and basal anterior , anteroseptal and lateral  wall hypokinesia with no significant valvular lesions  All other laboratory investigations were unremarkable except for Positive Troponin , Elevated CKMB 180 and un controlled diabetes Markedly ( elevated HBA1C ) 

LM : Atherosclerotic vessel with Total occlusion.RCA : Atherosclerotic vessel with non significant lesions , giving retrograde collaterals to left system .

Engagement of LM with Guiding Cath XB 3.5 7F, Wiring of LAD with FIELDER XTA over a CARAVEL MC  ,The wire succeeded  to go easily so we decided to confirm wire position through retrograde injection that shows the wire in a Diagonal branch , We decided to open LM first with a 3.25 * 15 mm Balloon , We exchanged the Diagonal wire with a regular wire and another wire was introduced into LCX with confirming positions with both ante and retrograde injections , We tried to negotiate the Mid segment CTO LAD with FIELDER XTA wire over the MC , The wire go through dissection , so left in place and another parallel wire was used to track true lumen , The ( Runthrough ) wire succeeded to track true lumen Confirmed by retrograde injection , Confirming we are True Lumen with MC injection, Then PTCA at site of CTO with 2 * 15 mm Balloon , Stenting of Ostial LM-LAD with 4 * 23 DES with post-dilatation , and we decided not to stent whole LAD dissection ( INVESTMENT PROCEDURE )  and to perform control angiography again , which was done three month later showing midsegment LAD lesion which was stented with 3 * 48 mm DES and treated distally with Drug coated balloon with final good angiographic results and TEMI III flow  

In Conclusion , According to Esc guidelines for Risk Stratification of NON-STEMI patient , he  is considered high risk  due to Dynamic ECG changes & Elevated cardiac enzymes . So, Early invasive PCI in the first 24 hours was indicated , But after angiography there was a debate about either to proceed to PCI or CABG , So we discussed with the Heart Team together with the respection of patient and close relatives decision and proceeded for a high risk procedure . Studies  suggest that MS is associated with an increased risk of cardiovascular  disease that is  related to genetic factors & inflammatory process.In a high risk PCI , study your patient well , put a proper plan , Be well equipped .