A patient with hemophilia type B presented with unstable angina and was found to have severe 3-vessel coronary artery disease with bifurcation lesions in the LAD/Diagonal and first obtuse marginal, and also severely calcified lesions in the right coronary artery. He turned down coronary bypass graft surgery and was referred for multivessel PCI. The LAD/Diagonal bifurcation was treated with provisional stenting: a guidewire was jailed in the diagonal, facilitating rewiring and kissing balloon inflation with a nice final result, without the need for diagonal stenting. The RCA lesions were balloon uncrossable and balloon undilatable. After using a guide catheter extension rotational atherectomy was done, followed by use of the distal anchor technique to deliver stents. Stents were dilated at high pressure providing a nice final result as confirmed by intravascular ultrasonography.

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