74-year-old obese male on HD presented with CCS Class II angina and positive SPECT MPI on July 14, 2020 done as pre-op for renal transplant revealing moderate apical, inferior and inferolateral ischemia. A Cardiac Cath on August 20, 2020 revealed 3 V CAD: 70% mid RCA, 100% RCA-AV Cont, subtotal calcified mid-distal LAD, 60% D1, 80% LCx-OM2, 80% LCx-LPL1, LVEF = 55% and SYNTAX Score of 33. Heart discussion followed and patient declined CABG. Patient is now planned for high risk multivessel PCI with appropriate use of IVUS, rotational atherectomy and Impella LV assist as needed.