53 year old male with CKD on HD, known extensive inoperable severe calcific CAD and s/p SAVR in Nov 2017, now presented with NSTEMI and TnI 8.5. A Cardiac Cath on October 30, 2018 revealed severe calcific 3 V CAD: new totally occluded calcified prox LCx, known CTO of D1 & Ramus and multiple 80-90% lesions of mid, distal RCA and RPDA with SYNTAX score of 53 and LVEF 45%. Patient underwent successful intervention of culprit calcified proximal LCx using Rotational Atherectomy and DES (5/18mm Resolute Onyx). Patient did well and continued to mild angina and dyspnea. Patient is now planned for staged PCI of severely calcified RCA lesions using Rotational Atherectomy (step burs) and multiple drug eluting stents.