Percutaneous coronary interventions (PCI) on complex unprotected left main stem (LMS) lesions involving rotational artherectomy are technically challenging and high risk cases. There is limited experience in performing these cases via a radial approach. We report a case of an unstable patient with severe distal LMS disease in whom cardiac surgery, intra-aortic balloon pumping and femoral approach were all contraindicated, who was successfully treated via a radial approach. We also review the technical challenges of LMS PCI through a radial approach.