Difficulty in identifying the culprit lesion in ST-elevation myocardial infarction with marked coronary tortuosity.

UNLABELLED: We report a 90-year-old woman with ST-segment elevation myocardial infarction. Twelve-lead electrocardiography and transthoracic echocardiography suggested a lesion from the anteroseptum to the apex, implicating the left anterior descending artery (LAD). Coronary angiography showed marked tortuosity of the left coronary artery, complicating identification of the occluded LAD. Careful multi-angle evaluation enabled successful reperfusion. This case demonstrates that coronary artery tortuosity (CAT) can hinder culprit lesion identification. Although CAT is associated with myocardial ischemia, its impact on identifying the culprit lesion is rarely reported. Awareness of this scenario is important as tortuosity increases with aging. LEARNING OBJECTIVE: Coronary artery tortuosity (CAT) can complicate the identification of the culprit lesion in acute myocardial infarction. Careful and systematic interpretation of coronary angiography, in conjunction with electrocardiography and echocardiographic findings, is essential for successful percutaneous coronary intervention in tortuous coronary arteries. With the aging population, the prevalence of CAT is increasing, highlighting the need for heightened clinical awareness and preparedness for complex coronary interventions.