This is a 52 years old gentleman with background history of hypertension and dyslipidemia and is a non smoker .  He was referred to National Heart Institute  ( IJN ) following a missed inferior myocardial infarction. 
His physical examination is unremarkable

ECG : Sinus Rhythm , Q wave inferior leads with reciprocal ST depression over anterolateral leads
Trop T : 360 pg/ml
Echocardiogram :Ejection Fraction : 47% Hypokinesia involving inferior basal , inferior mid , mid septal regionTAPSE : 2.6cmmild Mitral Regurgitation

left main stem :  normal 
Left Anterior Descending Artery : severe stenosis proximal 
Left Circumflex Artery : severe stenosis proximal 
Right Coronary Artery : severe stenosis proximal followed by CTO segment from midsegment , calcified, collateral from left system

PCI CTO RCA Right femoral approach with AL 1.0,6 Fr guiding  Wire RCA (RDPA) with runthroughfloppy wire (RTF) with caravel microcatheter. sequential pre-dilatation with semi compliant (sc) balloon 1.5/15mm and 0.75/10mm Failed to pass down bigger balloonWire to RV branch with RTF wire Balloon anchor technique attempted predilate with sc balloon 1.0/15mm, however, unable to pass balloon distally  Decided to proceed with rotablation Exchange RTF with ROTA floppy ROTA Burr 1.5mm from proximal to distal RCA: 4-5 runs 160-170rpmsequential predilatation with sc balloon 2.0/15mm and scoring balloon 2.5/15mm stented distal RCA with DES 2.75/38mm stented proximal to distal RCA with DES 3.5/38mm post dilatation NC balloon 3.5/20mm  PCI to LAD- Diagonal EBU 3.5/ 6 FR guiding catheter with left femoral accessRTF wire to distal LADPredilatation with sc balloon 2.0/15mmand scoring balloon 2.5/15mm cross ostial diagonal with RTF wire with microcatheter predilate diagonal with sc balloon2.0/15mm (POBA)noted non flow limiting dissection at LAD/Diagonalstented ostial to prox LAD with DES 3.0/48mm at post dilatation with NC 3.5/20mm flip flop wire LAD to Diagonal with wire support kissing balloon inflation 3.5/20mm – LAD 2.0/15mm – Diagonal  PCI to LCx RTF to distal LCx Predilate with scoring balloon2.5/13mm Stented mid LCx with DES 3.0/22mmPost dilatation with 3.0/15mm TIMI III flow 

Complex calcified lesions are challenging and rotational atherectomy may be used as augmentation therapy along with modified balloon for optimal lesion preparation and coronary stenting .
Other strategies may involve use of microcatheters , anchor balloon technique to facilitate crossing complex lesion and operator should be prepared to escalate treatment with debulking technique such as rotablation to achieve successful revascularization.
Multivessel coronany angioplasty  with complex lesion is a high risk endeavor and may involve long procedure time. Hence , operator need to anticipate possible adverse events and manage complication accordingly when the need arises.