72 year old NIDDM male with prior CABG (2012) and PCIs presented with CCS Class III angina, dyspnea and right leg claudication. A SPECT MPI revealed moderate inferior and inferolateral ischemia. A Cardiac Cath on May 3, 2018 revealed 3 V CAD, in-stent restenosis CTO of proximal RCA (distal vessel fills via LAD collaterals), 80% proximal LAD, 80% proximal LCx and 95% proximal Ramus with occluded SVG to RCA, to Ramus and to LCx-OM1, patent LIMA to LAD and LVEF 60%. Patient underwent successful intervention of proximal LCx using DES (Xience Alpine 3x12mm) and PTCA of Ramus. Patient still has CCS Class II symptoms on GDMT including three antianginals. Patient is now planned for recanalization of proximal RCA CTO in-stent restenosis via antegrade or retrograde approach followed by Rotational or Excimer laser atherectomy and DES implantation.