76 year old male with severe extensive aneurysmal PAD, presented with new onset CCS Class II angina and positive SPECT MPI for moderate inferior ischemia. A Cardiac Cath on March 13, 2018 revealed 3V + LM CAD: 70% distal LM bifurcation (Medina 1,1,1), 90% proximal LAD, 80% proximal LCx with small subtotal OM, 90% RCA-RPL2, SYNTAX Score of 28 and LVEF 70%. Patient underwent Heart Team discussion and high risk PCI was recommended based on the patient’s wishes. Now planned for IVUS guided unprotected left main bifurcation PCI using DK Crush technique via radial access.