Background Patients undergoing coronary artery bypass grafting (CABG) sometimes have critical proximal lesion in left anterior descending (LAD) artery or chronic total occlusion followed by either skip lesions or diffuse disease of late mid to distal LAD artery. Such lesions require endarterectomy or atheroma bridging via long venous or arterial patch (patch-plasty), for which clinical outcomes are conflicting in studies due to a more thrombogenic milieu created by patch-plasty as well as incomplete endarterectomy. We present a hybrid approach with Drug Coated Balloon (DCB) angioplasty of mid to distal LAD through LAD arteriotomy followed by Left Internal Mammary Artery (LIMA) insertion to LAD. Case Summary A 35-year-old man who was thrombolysed for anterior wall myocardial infarction in another city, reported to our hospital 4 weeks later with persistent angina. Coronary angiography showed severe multivessel coronary artery disease. There was diffuse disease in LAD distal to potential site of LIMA insertion and needed patch plasty. We carried out a hybrid procedure by performing DCB angioplasty of mid to distal LAD through the LAD arteriotomy site during CABG followed by LIMA insertion to the LAD. The patient remained asymptomatic post procedure with a 6-month follow-up CT scan showing patent LIMA & mid to distal LAD. Discussion This case shows a novel technique, first in the world, of performing angioplasty during CABG through arteriotomy followed by graft insertion.