Anomalous right coronary artery (RCA) arising from the left sinus of Valsalva presents a challenge during angiography, often leading to failed engagement, prolonged procedure time, and delayed reperfusion. This case highlights an innovative technique in which a standard guide catheter was manually modified to mimic a Leya catheter when the dedicated device was unavailable, allowing timely revascularization. A 47-year-old man presented with chest pain and elevated troponin, consistent with non-ST-elevation myocardial infarction. Angiography showed an anomalous RCA taking off anterior and superior to the left main coronary artery. Several standard diagnostic and guiding catheters failed to engage the vessel; the procedure was then switched from radial to femoral access, and an Amplatz Left 1 (AL1) guide catheter was manually modified by applying a 45–60° right-angled twist at the tip to reproduce the curvature of a Leya catheter. This modification allowed stable engagement of the RCA and successful percutaneous coronary intervention. In patients with anomalous RCA where standard catheters fail, manual modification of a guide catheter to achieve optimal engagement can be a useful alternative when a dedicated design is unavailable. Femoral access is preferred in difficult cases, especially with anomalous RCA, as it provides greater stability and facilitates successful engagement.

Massive overdose of calcium channel blockers and angiotensin-converting enzyme inhibitors can result in refractory mixed vasoplegic and cardiogenic shock. We present a case of a 65-year-old woman with severe amlodipine and lisinopril overdose requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Despite improved systemic perfusion, the patient developed left ventricular distension characterized by reduced pulsatility, elevated pulmonary capillary wedge pressure, and severely depressed left ventricular function. Early placement of an Impella device for active left ventricular unloading resulted in improved hemodynamics, restoration of pulsatility, and recovery of ventricular function. The patient was successfully weaned from mechanical support with full clinical recovery. This case highlights the importance of hemodynamic-guided left ventricular unloading during VA-ECMO in toxicologic shock and supports the role of ECpella in selected patients.