A 73 year old man was admitted with haematemesis and was found to have a pangastritis. Three days later he developed central chest pain, and ECG changes indicated an acute anterior myocardial infarction. In view of his recent haematemesis we performed emergency coronary angiography, which showed proximal occlusion of the left anterior descending (LAD) artery (TIMI 0 flow), with normal circumflex and right coronary arteries. We proceeded to primary percutaneous transluminal coronary angioplasty (PTCA) with a 7 French left 4.5 Judkins guide, a Magnum wire (Schneider UK, Staines, Middlesex, UK), and a 3.5 mm Viva balloon (Boston Scientific Ltd, St Albans, Herts, UK). Unfractionated intravenous heparin 10 000 units was given. The lesion was crossed with Magnum wire and injections at that time showed TIMI 1 flow. The site of occlusion was dilated with the 3.5 mm balloon to 6 then 8 atm with subsequent TIMI 0 flow. Dissection was thought to be the most likely cause of the no-reflow phenomenon and a 3.5 × 34 mm …