A 76-year-old male presented with chest pain, breathlessness, and sweating, indicative of a high-risk acute coronary syndrome suggestive of an evolving anteroseptal STEMI. Coronary angiography revealed critical multi-vessel, multi-lesion atherosclerotic coronary artery disease with left main disease: LMCA shows diffuse disease extending into LAD and LCX; LAD has a Type III vessel with ostio-proximal 100% occlusion (acute on chronic), filling via collaterals from LCX; LCX has an ostial 80% stenosis with normal distal segments; and RCA, the dominant vessel, shows a mid-segment 100% chronic total occlusion with collaterals from LCX, distal RCA, and PDA being fairly clean. An attempted primary PCI to LAD failed as the 0.014" SION J guide wire could not cross the total occlusion, suggesting a chronic total occlusion, leading to procedure termination. The patient was shifted to CR for further management, and a CVTS opinion has been sought.