84 year old female with IDDM and prior CVA, presented with CCS Class IV angina after a small NSTEMI and had positive stress MPI with mild apical and anterior ischemia. A Cardiac Cath on January 2, 2018 revealed LM and 3V CAD: CTO of calcified proximal RCA, 70% distal left main bifurcation with 90% proximal LAD and 70% proximal LCx (Medina 1,1,1) and 80% mid LAD (Medina 1, 0,0) bifurcation with SYNTAX score of 41 and LVEF 50% due to inferopical hypokinesis. Patient underwent Heart Team discussion and CABG was declined due to advanced age and high STS score of 8.2. Patient is now planned for high risk PCI of unprotected LM bifurcation with dedicated two stent technique, IVUS guidance and possible LV support device.