The anomalous origin of the coronary artery arising from the opposite sinus (ACAOS) is a rare coronary artery anomaly which potentially may cause coronary ischemia when an aortic intramural course of the vessel is present.1) When ischemia caused by a phasic compression of the intramural decourse is confirmed, stenting or surgical un-roofing are generally proposed. A 47-year-old hypertensive man with acute coronary syndrome and ST changes in the inferior-lateral wall underwent emergent coronary angiography. The left circumflex presented a sub-occlusive lesion which was treated with a III-generation drug-eluting stent (DES). The right coronary artery (RCA) originated from the opposite sinus with a decourse which appeared closed to the left stem, anterior to the aorta with no impingement (Figure 1). A computed tomography (CT) angiographic scan failed to clearly demonstrate an intramural course (Figure 2). Because of a residual thoracic discomfort and abnormal electrocardiogram, a new transthoracic echocardiogram was performed in order to ruling out eventual procedure-related complications. An intramural decourse of the proximal portion RCA was clearly visible in the parasternal short axis view (Figure 3). A new coronary angiography with intravascular ultrasound examination of the intramural course demonstrated a phasic compression of the intramural decourse not apparent on the previous coronary angiography (Figure 4). A III generation DES has been successfully implanted (Figure 5) with ST changes and symptomatology resolution (Figure 6). Emotional or environmental stress and hypertensive status may have a potential role in phasic lumen reduction of the proximal vessel lumen in case of ACAOS when an intramural de-course is present. A careful use of both non-invasive and ancillary invasive imaging tools are fundamental for the proper management of such rare anatomo-pathological entity.2)