Coronary artery injuries are uncommon. Acute injuries of major coronary vessels, particularly the left anterior descending artery (LAD), are life-threatening because of the significant cardiac dysfunction that ensues and usually requires repair or bypass. In contrast, late presentation of missile coronary artery injuries has been sporadically reported in the literature. Herein we present a 32-year-old lady from Sulaimania, Iraq with multiple shrapnel injuries 16 years earlier presented recently with severe anterolateral myocardial ischemia unresponsive to medical treatment. Coronary angiography and surgical exploration revealed shrapnel compressing the LAD. The patient responded very well to shrapnel extraction and coronary artery revascularization (off pump left internal mammary artery—LIMA—to LAD anastomosis). The management of this patient is discussed with review of relevant literature. It is concluded that long-standing shrapnel close to a major coronary artery may incur an external trauma initiating a localized arteriosclerosis with an extremely long time interval from injury to the onset of symptoms of myocardial ischemia.