50-year-old male on HD, extensive CAD presented with progressive CCS Class II angina and high risk SPECT MPI for multivessel ischemia as preop for renal transplantation. A Cardiac Cath on December 2, 2019 revealed 3 V CAD: 95% LCx bifurcation with CTO ISR of OM1 (Medina 1,1,1), FFR+ 60% mid LAD/D2 bifurcation (Medina 0,1,1), CTO ISR of mid RCA with LVEF = 55% and SYNTAX Score of 39. In view of multiple DES CTO ISR and CAD progression, patient was recommended to undergo CABG pre renal transplantation. After Heart Team discussion, patient declined CABG and placed on maximal medical therapy. Pt continued to be symptomatic despite maximal tolerated MT and is now planned for high risk intervention of LCx/OM1 bifurcation and to stage RCA/LAD intervention after one month.