A patient with prior PCI of the LAD presented with NSTEMI. Coronary angiography showed multivessel coronary artery disease with an under-expanded proximal LAD stent, distal left main disease, and proximal/mid RCA lesions. He was turned down for CABG and referred for PCI. The RCA and left main were successfully stented, but the LAD lesion remained undilatable despite intravascular lithotripsy (3.0 and 3.5 mm balloons for a total of 160 pulses), high pressure balloon inflation, Angiosculpt, SIS-OPN at 50 atm, orbital atherectomy at low and high-speed, and laser with contrast. After 9 min 52 seconds of rotablation with a 2.0 mm burr up to 225,000 rpm the lesion was crossed by the burr. Although expansion was better it was still suboptimal but using a 3.5 mm SIS-OPN balloon good stent expansion was achieved.