65-year old male with known long standing history of chronic ischemic heart disease requiring multiple PCI’s over the years after declining CABG, presented with CCS Class III angina and high risk stress MPI for multivessel ischemia. A Cardiac Cath on September 28, 2020 revealed 3 V CAD: 100% proximal RCA due to multilayer DES ISR (J-CTO Score = 3), 90% mid LAD, 80% LAD-D2, 95% small stent jailed LPL1, SYNTAX Score of 22 and normal LV systolic function. Patient underwent successful intervention of mid LAD and D2 using two (Xience Sierra) DES. Patient is now planned for staged PCI of RCA multilayer DES CTO ISR using rotational atherectomy and intravascular brachytherapy (IVBT) with OCT guidance for PCI optimization.