• Ostial LAD lesions should be considered true bifurcation lesions.

• IVUS guidance is highly recommended.

• The optimal technique appears to be cross over into left main with final POT.

Angiographic appearance of lesions that involve a bifurcation is often misleading. Intravascular ultrasound (IVUS) evaluation of distal left main (LM) lesions usually reveals that the disease is diffuse rather than focal. Continuous plaque from the LM into the left anterior descending artery (LAD) is seen in >90% of lesions; therefore, it is useful to consider angiographically ostial LAD lesions a true bifurcation lesion subset.