This case will illustrate the clinical and unique technical challenges, not previously reported, in a patient with a history of progressive left ventricular (LV) systolic dysfunction, congestive heart failure (CHF), myocardial infarction (MI), and a complex bifurcation lesion of the left subclavian artery (SA) involving the left internal mammary artery (LIMA) in the setting of coronary subclavian steal syndrome (CSSS). The approach to this lesion is complicated by significant LIMA involvement requiring intervention directed toward both the SA and the LIMA in the presence of severe LV systolic dysfunction. This clinical scenario necessitates a careful technique, utilizing bifurcation methods similar to those used in coronary intervention.