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asif h. khan , ian b. a. menown , alastair graham and john a. purvis declare no conflicts of interest .
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 we present the case of 56-year - old woman who required complex coronary artery bypass grafting for high - risk anomalous left main coronary artery ( lmca ) originating from right coronary cusp including conventional reimplantation of the lmca plus left internal mammary artery ( lima ) graft to the left anterior descending ( lad ) and saphenous vein graft ( svg ) to the left circumflex ( lcx ) . on subsequent cardiac computed tomography screening and cardiac catheterization , 
 the lima graft was occluded after just a few centimeters , but the svg graft was patent with good run - off into the native lcx and also filled the lad retrogradely . 
 the reimplanted left main stem demonstrated at least moderate ostial stenosis although pressure wire assessment of this was not significant ( fractional flow reserve 0.89 ) , probably due to good retrograde filling of the lad from the svg to lcx , therefore , we did not proceed with ostial lmca stenting . 
 she remains on yearly review with a low threshold for further revascularization should the svg to lcx develop progressive stenosis . 
 this case illustrates how patients with anomalous lmca may sometimes benefit from grafting in addition to conventional reimplantation.electronic supplementary materialthe online version of this article ( doi:10.1007/s40119 - 015 - 0039-x ) contains supplementary material , which is available to authorized users . 
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