81 year old male with known CAD, prior CABG (2006) and CoreValve TAVR (Jan 2015) now presented with crescendo exertional angina despite optimal medical therapy. A pharmacological MPI revealed moderate to severe lateral and inferolateral ischemia. Patient had known jeopardized calcified 90% left main and 80% circumflex disease pre-TAVR with occluded aortic anastomosis of diagonal and OM vein graft with patent jump segment. Patient continues to have Class III angina despite maximal anti-ischemic therapy. Now planned for protected left main and circumflex DES PCI through CoreValve struts using Guideliner and Rotational Atherectomy.